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Spotlight Case June 2005. Getting to the Root of the Matter. Source and Credits. This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at CME credit is available through the Web site

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Spotlight Case June 2005

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spotlight case june 2005

Spotlight Case June 2005

Getting to the Root of the Matter

source and credits
Source and Credits
  • This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case
  • See the full article at
  • CME credit is available through the Web site
    • Commentary by: Scott Flanders, MD; Sanjay Saint, MD, MPH
    • Editor, AHRQ WebM&M: Robert Wachter, MD
    • Spotlight Editor: Tracy Minichiello, MD
    • Managing Editor: Erin Hartman, MS

At the conclusion of this educational activity, participants should be able to:

  • Appreciate the goals and limitations of root cause analysis
  • Outline the steps to conduct root cause analysis
case getting to the root of the matter
Case: Getting to the Root of the Matter

A 65-year-old man with atrial fibrillation, lung cancer, and chronic renal insufficiency presented to ED with shortness of breath. Vitals signs were significant for respiratory rate of 32, temperature of 102.4°F, oxygen saturation of 87% on 100% non-rebreather. Chest X-ray showed a right middle lobe infiltrate. Due to respiratory distress, the patient was intubated.

case cont
Case: cont.

The patient became hypotensive with a systolic blood pressure (BP) of 65 mm Hg. While continuing fluid resuscitation, BP was supported with phenylephrine and vasopressin. Phenylephrine was changed to norepinephrine. After 8 hours, arterial blood gas revealed pH 7.23, PCO2 23 mm Hg, PO2 161 mm Hg, BE –16, lactate 6.2 mmol/L (normal 0.5 – 2.2 mmol/L).

case cont6
Case: cont.

A pulmonary artery catheter was placed, and initial numbers were—surprisingly—more consistent with cardiogenic shock than septic shock. Central venous pressure was 13-17 mm Hg, pulmonary capillary wedge pressure 19 mm Hg, cardiac index (CI) 1.8 L/min/m2, and systemic vascular resistance (SVR)1500 dynes/sec x cm-5.

case cont7
Case: cont.

Norepinephrine was weaned rapidly. The patient remained on vasopressin. An ECG showed global decrease in contractility, with an ejection fraction of 45% and mild right ventricular dilatation. Shortly thereafter, it was discovered that the patient had been receiving 0.4 units/min of vasopressin, rather than the intended dose of 0.04 units/min. Vasopressin was discontinued.

case cont8
Case: cont.

Within the next few hours, the patient’s condition improved. The CI and mixed venous oxygen saturation increased to 3.8 L/min/m2 and 75%, respectively, and the SVR decreased to 586 dynes/sec x cm-5. A creatine kinase (CK) peaked at 7236 U/L, CKMB at 37 U/L. The patient was treated with fluids and antibiotics, and had an uneventful recovery.

root cause analysis
Root Cause Analysis
  • Investigation of a serious adverse event or close call
  • Performed by a team with expertise in the area whose members were not directly involved with the error
  • Team typically organized by patient safety or quality improvement program
goals of root cause analysis
Goals of Root Cause Analysis
  • What happened
  • Why did it happen
  • What can be done to prevent it from happening again
root cause analysis11
Root Cause Analysis
  • Assess environment of the error and identify system vulnerabilities rather than individual culpability
    • Observe work environment
    • Interview staff involved
    • Review incident reports of similar errors
    • Propose realistic suggestions for change

Bagian JP. Jt Comm J Qual Improv. 2002;28:531-545.

performing root cause analysis
Performing Root Cause Analysis
  • How would you do it?
  • What would you be likely to find in this case?
  • What solutions could be implemented?
performing root cause analysis13
Performing Root Cause Analysis
  • Establish the team
    • Leader from patient safety
    • ICU physician
    • ICU nursing (manager and staff)
    • Pharmacist
    • ER physician
    • Trainees (resident and fellow)
performing root cause analysis14
Performing Root Cause Analysis
  • Step # 1—Develop timeline of events
    • All provider contact with the patient (from physician to patient transport)
    • All orders
    • All tests, test results
  • Step #2—Generate a differential diagnosis for systems factors that may have contributed to the error
rca timeline
  • Fellow tells resident to start patient on vasopressin
  • Resident uses computerized order entry system. Multiple doses of vasopressin are available. He orders vasopressin 0.4 units/min instead of 0.04 units/min
  • Nurses deliver the medication for 16 hours
rca timeline16
  • Team rounds on patient next morning, including attending, pharmacist, nurses, and trainees
  • During an orientation tour, nurse informs nursing students that patient is receiving vasopressin at a dose of 0.4 units/minute
  • ICU fellow overhears this and realizes the patient is receiving the wrong dose
rca differential diagnosis
RCA—Differential Diagnosis
  • No ICU protocols for high-risk procedures or for the use of high-risk drugs
  • Poor staff / trainee teamwork skills
  • No systematic process in the ICU for reviewing key aspects of patient care during daily rounds
rca differential diagnosis18
RCA—Differential Diagnosis
  • No nursing guidelines or protocols for use of vasopressor medications
  • No process in pharmacy to highlight medications used in differing doses for different indications
rca analyzing contributing factors
RCA—Analyzing Contributing Factors
  • No ICU protocols for high-risk procedures or for the use of high-risk drugs
    • Preventable adverse drug events common in ICU
    • Vasopressin, given narrow therapeutic window and serious adverse cardiovascular effects, should be flagged as a high-risk medication
    • Protocols should be developed for high-risk medications

Bates DW. JAMA. 1995;274:29-34.Mutlu GM, Factor P. Intensive Care Med. 2004;30:1276-1291.see Notes for complete references

rca differential diagnosis20
RCA—Differential Diagnosis
  • Poor staff / trainee teamwork skills
    • Vasopressin order incorrectly written by resident after receiving a verbal order from his supervising critical care fellow
    • Unlikely that the fellow asked the resident whether he understood the order or had used vasopressin previously in patients with septic shock
    • Unlikely that verbal order was followed by a “read back” by trainee
rca differential diagnosis21
RCA—Differential Diagnosis
  • No systematic process in the ICU for reviewing key aspects of patient care during daily rounds
    • ICU physician rounding process rarely includes a regular assessment of medication doses, drug interactions, or key error prevention and patient safety steps
    • Pharmacists not always included

Saint S. Ann Intern Med. 2002;137:125-127.

rca differential diagnosis22
RCA—Differential Diagnosis
  • No nursing guidelines or protocols for use of vasopressor medications
    • Nursing in this ICU did not follow set protocols related to the use of vasopressors
    • No systematic review of medication doses during nursing sign-out
    • No regular process of “double-checking” whether the right drug is being given to right patient at the right dose
rca differential diagnosis23
RCA—Differential Diagnosis
  • No process in pharmacy to highlight medications used in differing doses for different indications
    • CPOE in place, but merely implementing CPOEor a barcoding system will not eliminate medication errors
    • CPOE system did not ask for the indication, nor flag the order for pharmacist to review

Kaushal R. Arch Intern Med. 2003;163:1409-1416.

Nebeker JR. Arch Intern Med. 2005;165:1111-1116.

rca system solutions
RCA—System Solutions
  • Most institutions respond to such errors by patching “small leaks” in systems that have created the error
  • Most long-lasting changes result from complete system redesign
  • Most institutions are reluctant to commit the resources and effort required for such changes

Bates DW. Ann Intern Med. 2002;137:110-116.

rca system solutions25
RCA—System Solutions
  • Redesign medication delivery process employing multidisciplinary approach
    • Reconcile all medications on admission and discharge from ICU
    • ICU safety officer rounds with team reviewing all medication
    • At minimum, team, including pharmacist, reviews all medications on rounds

Pronovost P. J Crit Care. 2003;18:201-205. Leape LL. JAMA. 1999;282:267-270. Keely JL. Ann Intern Med. 2002;136:79-85.

rca system solutions26
RCA—System Solutions
  • High-risk medications need to be treated similarly to high-risk procedures
    • “Time outs” before administration
    • Program standard dosing scales into IV pumps
  • Implement teamwork training for all ICU staff, physicians, nurses, and trainees
    • Include role-playing and simulations to improve team dynamics and communication
rca system solutions27
RCA—System Solutions
  • Create a forum that allows residents, fellows, and other team members to openly discuss errors
    • Morning report or morbidity and mortality conference

Wu AW. JAMA. 1991;265:2089-2094.

rca system solutions28
RCA—System Solutions
  • CPOE system should remind physician that a drug like vasopressin has more than one indication; then query the indication and provide suggested dose
  • Overridden computer-generated recommendations ideally would be flagged for immediate pharmacist review
  • Smart systems could include admitting diagnoses, and by combining that with patient location (ICU or ward) flag a drug or dose as potentially incorrect
rca caveats and limitations
RCA—Caveats and Limitations
  • Works best in reducing rare events
  • Proposed system solutions must be feasible
  • All changes should be re-evaluated periodically to ensure the process is indeed safer and achieving the desired outcomes
take home points
Take-Home Points
  • RCA is an important tool for reducing serious, rare adverse events
  • Multidisciplinary approach and commitment of resources is necessary to employ successful solutions
  • Changes should be evaluated regularly to assure efficacy

Wu AW. JAMA. 1991;265:2089-2094.