Quality Improvement-Case: Root Cause Analysis Case Vignette

Case: Root Cause Analysis Case Vignette

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In this case vignette, a patient with a previous history of IV drug abuse presented with a fractured wrist and humerus after a motorcycle accident. Despite being sent home after an initial evaluation, the patient returned with increased pain and other concerning symptoms. It was eventually determined that she had compartment syndrome, a serious condition that was initially missed by the healthcare providers. <br /><br />Several factors contributed to the missed diagnosis. These included a bias against the patient due to her history of drug abuse, fatigue of the on-call resident who evaluated her in the middle of the night, an equivocal exam, and the lack of a pressure monitor system being employed. Additionally, the senior resident did not come in to evaluate the patient and determine the proper course of action. <br /><br />Root Cause Analysis is a method used to analyze serious adverse events in healthcare. Instead of focusing on individual mistakes, it seeks to identify underlying problems in the system that increase the risk of errors. The 5 Whys strategy is a simple technique used in root cause analysis to determine the cause-and-effect relationships behind a problem. In this case, the cause-and-effect relationships that led to the missed diagnosis of compartment syndrome were identified as a result of this technique. <br /><br />The cause-and-effect (fishbone) diagram is another method used in root cause analysis. It explores and illustrates all possible causes of an issue by examining the inputs of every process involved. In this case, the diagram identified problems such as a poorly calibrated or broken pressure monitor device, lack of communication between the emergency department and orthopaedics, and a culture within the residency program that discouraged seeking help and support. <br /><br />Overall, it is important to understand that adverse events are often a result of system failures rather than individual errors. Punishment and blame do not effectively prevent future errors. Instead, focusing on improving the system and creating an environment that supports communication, collaboration, and proper evaluation of patients is crucial in preventing similar errors from occurring in the future.

Keywords

compartment syndrome

missed diagnosis

healthcare providers

bias against patient

fatigue of on-call resident

equivocal exam

lack of pressure monitor system

Root Cause Analysis

fishbone diagram

system failures