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Review the case at the U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research, “Getting to the Root of The...

A root cause analysis takes place when a team of experts that is not directly involved in an event examines a serious adverse event or a close call that occurred during treatment of a patient in a healthcare setting. The investigation is intended to reveal what happened, why it happened, and how this event could be prevented in the future.


In this case, the incident that triggered a root cause analysis was that the patient suffered a myocardial infarction (MI) that was probably the result of a prescribing error. The problem should be investigated, as the patient was receiving the wrong dose of medication (according to the article, "the patient had been receiving 0.4 units/min of vasopressin, rather than the intended dose of 0.04 units/min"). The reason for this error should be investigated so it can be prevented in the future. 


The steps necessary to conduct the root cause analysis are to produce a timeline to investigate why the patient received the wrong dose of medication, analyze contributing factors, and come up with systems solutions to prevent this error from occurring in the future. The goals are to reduce errors in treating patients, and the limitations are that the proposed solutions have to be doable and not waste clinicians' time or prove to be ineffective.

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