Root Cause Analysis Assignment
The student will be given a real-life case scenario where a Root Cause Analysis must be performed. The student will be able to dissect different sources and evaluate what models must be used to come to a conclusive root cause.
The Joint Commission framework template must be used for completion of this assignment
Please use the Guidelines for Root Cause Analysis document as a resource to help you get through this assignment.
Scenario to be completed in the assignment:
Adverse Drug Event
An 88-year-old woman with dementia, a history of hypertension, and coronary artery disease (post coronary artery bypass graft) was sent from her nursing home to the Emergency Department for worsening confusion. She had been admitted to the hospital six weeks earlier and treated for urosepsis, at which time an allergy to levofloxican was noted.
Initial evaluation revealed leukocytosis and pyuria, but no fever or flank pain. The Emergency Department physician concluded that a urinary tract infection was the most likely cause of the patient’s altered mental status and elected to treat her with levofloxacin.
The first dose was administered on the medical floor shortly after the patient arrived.
Over the next six hours, the patient became increasingly agitated and required sedation and restraint. She developed a diffuse erythematous rash across the chest and back, swollen lips and tongue, and audible wheezes. Concern was raised of an anaphylactic reaction.She was transferred to the Intensive Care Unit (ICU) where she was treated with intravenous corticosteroids, an antihistamine, and inhaled beta agonists. The levofloxacin was changed to an intravenous cephalosporin.
After the event, the patient’s paper chart was brought to the ICU from the Medical Records Department. The discharge summary from her previous admission reported an allergic reaction to levofloxican. The patient’s daughter, on arrival to the hospital later that evening, was exasperated to learn of her mother’s condition. She said, “You’re supposed to help her get better, not worse!”
Questions for Participants
Should the nursing home physician confer with the Emergency Department physician at the time of ED evaluation?
Should a demented patient wear a medical alert wristband?
Is there a trade-off between clinicians’ attempts to provide timely care — such as rapid administration of antibiotics and other treatments — and safety?
Interviews Following Case: Adverse Drug Event
The Emergency Department Physician
“I saw the patient and requested her records. I thought about treating her UTI with a cephalosporin, but the nurse told me the patient had very thin veins and tenuous IV access. I thought a quinolone made sense because you can take it orally. I reviewed the transfer sheets from the nursing home record and saw no note of an allergy. Unfortunately the patient was too sick to tell me about her allergies. I wish I’d waited for the chart to come up from Medical Records, but there was a trauma case coming in and we needed the bed.”
The floor nurse
“It was a busy day. We had four admissions all at once. I settled the patient and went on to help the other nurses. I administered all my patients’ medications, but I didn’t get a chance to sit down and do my paperwork until the end of the shift. I then remembered hearing about the patient’s last admission and recalled there was an allergic reaction to levofloxican. But by that time, she was already wheezing and swollen. We all rely on the doctors and pharmacists too much to get the order right.”
The pharmacist
“What a catastrophe! I remember receiving the order for levofloxacin. The pharmacy computer showed that the patient had no known drug allergies. We dispensed the drug and sent it up to the floor. Although the pharmacy computer keeps a record of every drug allergy that is brought to our attention, there is no consistent way that the information gets to us. If it is written in an admission note or discharge summary but not on the physician order sheet, there is no way we would learn of the allergy. We do the best we can, but we need some help from the clinicians.”
The daughter
“I am beyond exasperated. I know that things are busy and that the doctors and nurses here try to do the right thing, but they ought to know better than to give my mother a medicine she’s allergic to. If you can’t get a simple thing like that right, how can patients expect that you’ll get it right when you do something complicated? What’s so hard about saving allergy information in a single place so everyone can find it? I know all about my mother’s allergies and medications. Why couldn’t somebody give me a call?”
