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Difficulty: MediumRoot Cause Analysis and Error Investigation

A 72-year-old man is admitted to the medical ward for treatment of community-acquired pneumonia. On hospital day 2, blood cultures grow Pseudomonas aeruginosa. The attending physician enters an order in the electronic health record (EHR) to change the patient's antibiotic regimen to intravenous cefepime. During the evening shift change, the day nurse provides a brief verbal sign-out to the night nurse but omits the information about the antibiotic change due to multiple simultaneous patient alarms sounding on the unit. The night nurse relies on a printed handoff sheet from earlier in the day, does not check the updated EHR orders, and administers the previously prescribed ceftriaxone. Over the next 12 hours, the patient's respiratory status deteriorates, requiring transfer to the intensive care unit. The hospital's patient safety committee is notified of the adverse event. Which of the following is the most appropriate approach for investigating and addressing this incident?

  1. Convene a multidisciplinary panel to conduct a root cause analysis of the eventAnswer
  2. B
    Perform a failure mode and effects analysis to identify potential future electronic health record vulnerabilities
  3. C
    Identify the handoff omission as the primary etiology and mandate focused retraining for the nursing staff
  4. D
    Limit the investigation to the day nurse's decision-making process to evaluate for the presence of anchoring bias
  5. E
    Report the day nurse to the state nursing board for negligence in patient care

Answer

Convene a multidisciplinary panel to conduct a root cause analysis of the event
The correct answer emphasizes convening a multidisciplinary panel for a root cause analysis (RCA). RCA is a retrospective, systems-based methodology used to investigate adverse events and near misses. The goal is to identify latent system vulnerabilities (e.g., environmental distractions, lack of standardized handoff tools, EHR alerting failures) rather than assigning blame to individuals at the sharp end of the error. A multidisciplinary team ensures all perspectives are considered when designing robust corrective actions.

Step-by-Step Solution

1
Identify the type of quality improvement scenario presented.
An adverse event (medication error leading to patient harm) has already occurred due to a combination of active errors and latent system factors.
Determining whether the event is prospective or retrospective dictates the correct analytical tool.
2
Select the appropriate framework for investigating a past adverse event.
Root cause analysis (RCA) is required to retrospectively analyze the incident.
RCA is designed to look backwards at an event to find underlying systemic causes rather than stopping at the surface-level human error.
3
Evaluate the composition of the investigating team.
A multidisciplinary panel involving all stakeholders (nurses, physicians, IT, administration) must be convened.
A diverse team ensures a comprehensive understanding of the complex system interactions that led to the error.

Key Concept

Root Cause Analysis (RCA)
Estimated Time:1m 0s
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Topics

Root Cause Analysis and Error Investigation

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