As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.For this Assignment, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.
The Assignment: (3–4 pages)
- Briefly summarize the salient facts of the New York Times article.
- Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
- Qualitatively assess how much each factor contributed to the error.
- Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.
By The New York Times
A Tampa surgeon who has been widely vilified and ridiculed for mistakenly amputating the wrong leg of a patient on Feb. 20 sought this week to regain both his license to practice medicine and a measure of his once-solid reputation.
In a three-day hearing before the state official who will make recommendations on his professional future, the surgeon, Dr. Rolando R. Sanchez, and his lawyer, Michael Blazicek, publicly presented their side of the story for the first time.
They said that a series of errors by other hospital personnel and the severely diseased condition of both legs led Dr. Sanchez to believe that he was operating on the correct leg.
The blackboard to which surgeons refer in the operating room at University Community Hospital in Tampa listed the wrong leg for amputation, as did the operating room schedule and the hospital computer system, testimony revealed. By the time Dr. Sanchez entered the operating room, the wrong leg had been sterilized and draped for surgery.
Some doctors who appeared as witnesses said that the leg Dr. Sanchez removed was in such poor shape that it would probably have been amputated in the future.
“It is my opinion that 50 — no, probably 90 percent — of the surgeons in this state would have made the same mistake that Dr. Sanchez made,” said Dr. Joseph Diaco, an expert witness for the defense who is a surgeon and teacher at the University of South Florida. Even a witness for the state suggested it was a mistake anyone could have made.
But Steven A. Rothenburg, the lawyer pressing the case against Dr. Sanchez for the Florida Agency for Health Care Administration, said that the surgeon should have checked other paperwork, including the patient’s consent form and medical history, both of which were available in the operating room.
“Isn’t it true,” he asked Dr. Diaco, “that Dr. Sanchez had the last clear chance before he picked up that knife and cut into that tissue” to make certain the correct leg was being removed?
Dr. Diaco said it was true.
Dr. Sanchez testified that he learned of his error from a nurse as he was still cutting through the leg of the patient, Willie King, 52. After reviewing the patient’s file, she had started to shake and cry. But by that point, he said, there was no turning back. “I tried to recover from the sinking feeling I had,” he testified, as his eyes grew moist and his voice trailed off.
In July, the state’s health agency suspended the medical license of Dr. Sanchez, who will be 51 this month, claiming he presented an “immediate and serious danger to the health, safety and welfare of the public.”
That order was issued after another patient of Dr. Sanchez, whom he had treated at another Tampa hospital, Town and Country, said that she had not given him permission to amputate a toe during a procedure to remove diseased tissue from her right foot.
Until this year, the state had received no complaints about Dr. Sanchez.
Mr. Blazicek said that Dr. Sanchez accepted that he should be disciplined for amputating the wrong leg but insists that he had done nothing wrong in the second case. Dr. Sanchez testified that he had not intended to remove the toe of the patient, Mildred Shuler, but that the diseased bone “popped” while he was removing deadened tissue, leaving the toe hanging by a tendon.
Had he done nothing, he said, a bare bone would have been sticking out, making the patient susceptible to further serious infection. Other medical witnesses for the defense supported Dr. Sanchez’s assertions.
Another surgeon later amputated Ms. Shuler’s right lower leg, which was the treatment Dr. Sanchez had initially recommended. The patient had refused the treatment.
Throughout the hearing, family, friends, colleagues and patients of the doctor wore buttons proclaiming, “I support Dr. Sanchez,” and they said he had been unfairly depicted as a sloppy surgeon.
“I would say it’s safe to say 99.9 percent of our members support Dr. Sanchez,” said Dr. Fred Reddy, a surgeon who is the immediate past president of the Hillsborough County Medical Association, which includes Tampa doctors. “He’s an excellent surgeon who made one mistake.”
Dr. Reddy said the state had been slow to go after doctors who had as many as 50 malpractice suits against them. He said that intense press attention was responsible for the state’s swift and unduly harsh actions against Dr. Sanchez.
Dr. Sanchez, a native of Tampa, received his medical degree from the New York University School of Medicine in 1975. From 1975 to 1981, he worked as an intern, chief surgical resident, and a fellow in vascular surgery at the New York University Hospital, Bellevue, according to his resume. From 1982 to 1987, he was an assistant professor of surgery and emergency medicine at the Albert Einstein College of Medicine in the Bronx as well as the coordinator of hyperbaric medicine at the Bronx Municipal Hospital Center. He returned to Tampa in 1988 to establish a private practice.
There was no organized support at the hearing for disciplining the doctor. The hearing officer will make a recommendation in the case to the Florida Board of Medicine, a panel of 12 doctors and three non-medical members appointed by the Governor. Dr. Sanchez could face a fine as well as the permanent revocation of his license.
Mr. King, whose diseased leg was removed at another hospital, received a $1.2 million settlement in the case from University Community Hospital and Dr. Sanchez.
He told reporters he did not know how Dr. Sanchez should be disciplined and said he did not hold the surgeon alone responsible for what happened to him. “There’s a problem there somewhere that needs to be corrected,” he said, “and I don’t know what it is, and I don’t know how to go about it.”
Dr. Rolando R. Sanchez, who faced a disciplinary hearing in Florida for mistakenly amputating the wrong leg of a patient. (Associated Press)
Root Cause Analysis
September 7, 2019
Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. 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. 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). It is one of the most widely used retrospective methods for detecting safety hazards .
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. 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). The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events.
|Table. Factors That May Lead to Latent Errors|
|Type of Factor||Example|
|Institutional/regulatory||A patient on anticoagulants received an intramuscular pneumococcal vaccination , resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.|
|Organizational/management||A nurse detected a medication error , but the physician discouraged her from reporting it.|
|Work environment||Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism.|
|Team environment||A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation.|
|Staffing||An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in hypoglycemic coma.|
|Task-related||An intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course.|
|Patient characteristics||The parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage.|
As an example, a classic paper described a patient who underwent a cardiac procedure intended for another, similarly named patient. A traditional analysis might have focused on assigning individual blame, perhaps to the nurse who sent the patient for the procedure despite the lack of a consent form. However, the subsequent RCA revealed 17 distinct errors ranging from organizational factors (the cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather than by medical record number) to work environment factors (a neurosurgery resident who suspected the mistake did not challenge the cardiologists because the procedure was at a technically delicate juncture). This led the hospital to implement a series of systematic changes to reduce the likelihood of a similar error in the future.
RCA is a widely used term, but many find it misleading. As illustrated by the Swiss cheese model , multiple errors and system flaws often must intersect for a critical incident to reach the patient. Labeling one or even several of these factors as “causes” may place undue emphasis on specific “holes in the cheese” and obscure the overall relationships between different layers and other aspects of system design. Accordingly, some have suggested replacing the term “root cause analysis” with “systems analysis.”
Effectiveness of Root Cause Analysis
Root cause analysis is one of the most widely used approaches to improving patient safety, but its effectiveness has been called into question. Studies have shown that RCAs often fail to result in the implementation of sustainable systems-level solutions. A 2017 commentary identified eight common reasons for ineffectiveness of the RCA process, including overreliance on weak solutions (such as educational interventions and enforcing existing policies), failure to aggregate data across institutions, and failure to incorporate principles of human factors engineering and safety science into error analysis and improvement efforts. The National Patient Safety Foundation has proposed renaming the process root cause analysis and action (RCA2)—emphasizing that a well-done RCA should yield robust corrective actions and risk reduction. As detailed in a 2016 Annual Perspective , safety experts agree that effective error analysis requires the active involvement of organizational leadership, training of specialized teams with expertise in safety science, focusing on stronger systems-level solutions, and measuring implementation and impact on outcomes. Given the considerable time investment required to perform a formal RCA, more abbreviated incident analysis techniques may be appropriate in some cases.
The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site surgery) since 1997. As of 2009, 25 states and the District of Columbia have mandated reporting of serious adverse events (increasingly using the National Quality Forum’s list of “ Never Events “), and many states also require that RCA be performed and reported after any serious event. Although no data are yet available on this subject, RCA use has likely increased with the growth in mandatory reporting systems.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers