![]() The tip was subsequently found inside the patient, requiring reoperation.Īn overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in hypoglycemic coma.Īn intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. During the procedure, the patient suffered an air embolism.Ī surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.Ī nurse detected a medication error, but the physician discouraged her from reporting it. Factors That May Lead to Latent ErrorsĪ patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization. The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors) (Table). RCAs should generally follow a prespecified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. It is one of the most widely used retrospective methods for detecting safety hazards. RCA thus uses the systems approach to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within health care systems that contribute to adverse events). A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. ![]() Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. Root cause analysis (RCA) is a structured method used to analyze serious adverse events. ![]()
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