A patient receiving the wrong procedure is a very serious event. It has been named a “never event” by The Joint Commission. For organizations that are trying to prevent these kinds of serious events from happening, there is value in looking at near misses, such as the case we’ll examine here in a root cause analysis. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
In our case, a patient was prepped for a surgery he didn’t need, even receiving spinal anesthesia. He was prepped for a procedure based on the advice of an orthopedist, who believed the patient to have an ankle trimalleolar fracture, which he did not.
Why did the orthopedist believe the patient to have a fracture? The radiologist who had reviewed the patient’s radiographs diagnosed the fracture. The orthopedist did not review the radiographs. The orthopedist did examine the patient’s ankle, but gained no new insight into the diagnosis. Additionally, the family/patient did not mention the previous diagnosis, possibly because they weren’t told of it, or didn’t understand it..
The radiologist diagnosed the fracture because there was a fracture shown on the radiographs, which were labeled with the patient’s name. However, it was later determined that the radiographs were actually of a previous imaging client. The radiographs were taken because the patient’s previous radiographs did not arrive in time.
Given no more information about this case, our analysis stops here. However, the next step for the medical facility involved would be to examine the radiography procedures to ensure that mislabeling incidents do not occur. Other causes listed in the map can also be examined, to determine where other improvements can be made.
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals..