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Difficulty: MediumRoot Cause Analysis and Error Investigation

A 68-year-old man undergoes an elective total knee arthroplasty. On postoperative day 2, he develops acute shortness of breath and pleuritic chest pain; a CT pulmonary angiogram confirms a pulmonary embolism. Review of the electronic medical record reveals that deep venous thrombosis prophylaxis was ordered by the primary surgeon, but the medication was never administered. The pharmacy system had placed an automated hold on the order because the patient's preoperative baseline creatinine was slightly elevated, but no notification was routed to the covering clinical team. The hospital's risk management department is tasked with addressing this adverse event. Which of the following is the most appropriate methodology to investigate and address this incident?

  1. Convene a multidisciplinary team to retrospectively map the event timeline and identify underlying system vulnerabilitiesAnswer
  2. B
    Conduct a Failure Mode and Effects Analysis on the pharmacy dispensing software to anticipate future medication holds
  3. C
    Implement a standardized structured handoff protocol to ensure pending pharmacy alerts are communicated between nursing shifts
  4. D
    Conclude the investigation by mandating individual retraining on venous thromboembolism prophylaxis for the involved providers
  5. E
    Attribute the error to a cognitive anchoring bias by the primary surgical team and require an awareness seminar

Answer

Convene a multidisciplinary team to retrospectively map the event timeline and identify underlying system vulnerabilities
This scenario describes an adverse event (pulmonary embolism) that occurred as a direct result of a system-level failure (the electronic medical record failing to notify the clinical team of a pharmacy hold). The most appropriate next step is to conduct a Root Cause Analysis (RCA). An RCA is a retrospective quality improvement process that brings together a multidisciplinary team to systematically map out the sequence of events, identify latent system vulnerabilities (the 'blunt end' of the error), and implement robust, system-wide solutions to prevent recurrence. This approach prioritizes a non-punitive culture of safety.

Step-by-Step Solution

1
Identify the nature of the event.
An adverse event (pulmonary embolism) occurred due to a missed medication administration.
Determining whether an event is a near-miss, adverse event, or potential future risk dictates the quality improvement tool used.
2
Determine the timing of the required quality improvement intervention.
The investigation must be retrospective because the event has already happened.
Retrospective analysis of an adverse event or sentinel event requires a Root Cause Analysis (RCA).
3
Select the appropriate methodology for a Root Cause Analysis.
Assemble a multidisciplinary team to map the timeline and identify latent system errors.
Effective RCA avoids individual blame and focuses on multifaceted system vulnerabilities.

Key Concept

Root Cause Analysis (RCA) is a retrospective, multidisciplinary process used to investigate adverse events by identifying underlying system vulnerabilities rather than focusing on individual blame.
Estimated Time:1m 15s
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Topics

Root Cause Analysis and Error Investigation

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