The patient is a 56-year-old man with several comorbidities who was admitted to the emergency department for decompensated heart failure. He was prescribed and administered carvedilol, which is contraindicated in acute decompensated heart failure. This describes a sentinel event, as it resulted in the unexpected death of the patient. Thus, it should be followed with root cause analysis (RCA).
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. All accredited organizations are expected to respond to sentinel events with a thorough and credible RCA and action plan.
RCA can be defined as “a retrospective process for identifying the basic or causal factors that underlie variation in performance.” RCA is a powerful tool used to improve systems, mitigate harm, and prevent recurrence of adverse events (by identifying root cause and generating action plans) without directing individual blame. These goals are accomplished through answering three questions:
What happened?
Why did it happen?
What can be done to prevent it from happening again?
RCA uses records and participant interviews to identify all the underlying problems (eg, process, people, environment, equipment, materials, management) that led to an error.
Conducting a failure mode and effect analysis (FMEA) or a drug utilization review (DUR) would not be correct in this situation because the adverse event has already occurred and the goal is to now identify the cause of this error. Both of these analyses are preventative measures and would not be able to pinpoint a direct cause for this medical error. Although preventing interruptions and distractions can help reduce errors to some extent, it would not help to identify the root cause of the adverse event that has already occurred. Retrospective root cause analysis, by contrast, helps target future efforts by illuminating systemic flaws and shortfalls to be addressed. Suspension of the medical resident and reporting to the program director will not help identify the cause of the adverse event.