Root Cause Analysis Paper

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Root cause analysis is the process that helps to identify the factors that contributed to the adverse effect or other noted incident (Wachter, 2012). It is a helpful process that can assist in avoiding making the same errors with another patient. Root cause analysis is a vital component of the investigation of the incident at hand. The scenario presented in this case study was that of a patient name mix up resulting in the wrong procedure for the wrong patient. These women's names were very similar and there was a mix up when scheduling two GI lab tests. Two women were seen in the same office for similar complaints about the gastrointestinal system. One was told to have routine blood work, while the other was going to do two tests. When the nurse …show more content…
It is realistic, as there is not many interventions that need to occur in order to implement a double check system. The timing issue would not be affected and an evaluation would be immediate. In an article by Elaine Dattilo, RN, wrong site surgery was discussed (2007). It expanded on the changes that were implemented by root cause analysis solutions to this problem. "Time outs" are now a part of every surgery and become part of a person's medical chart (Dattilo, 2007). In the scenario with the wrong patient, wrong procedure there was not a sentinel event that occurred, but there was the stage for something to occur. It was still an invasive procedure that was unnecessary for Mary Kainer to endure. "Seldom does a root cause analysis reveal only one action or one person responsible..." (Datillo, 2007). Root cause analysis has many contributing factors that lead to an adverse outcome. There were many contributing factors to the outcome that was in the scenario presented that could have been caught to avoid the outcome. For example, the name was only mentioned one time, no other identifiers, and a read

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