Application Root Cause Analysis Technique in Investigating the Causes of a Fatal Sentinel Event: Case Report

Medical errors are among the most challenging threats to health systems in all countries. Thus, it is essential to take actions to reduce the risk of sentinel events reoccurrence. Root cause analysis is one of the risk management models, used for retrospective analysis of the root cause or causes of errors and weaknesses in a system or its related processes systematically. This study aimed to analyze the root causes of a sentinel event led to death in one of the hospitals in Isfahan in 2015.
This is a case report study that analyzes root causes of medical errors. The study was consisted of seven steps including: determining an event that must be analyzed, organizing a team to run it, gathering relevant data, identifying problems, searching for the causes of the incident, providing solutions, implementing solutions, and assessing and writing research report that lasted for 9 months.
The results showed that the first reason was lack of policy and protocol, developed for how to triage patients from one service to other services in the hospital, which caused problems in managing and assuming the responsibility of the patient's administration. The second fundamental problem was the patient’s examination by different specialists regardless of the status and progression of the clinical symptoms of the patient that caused loss of key information in the process of the patient clinical symptoms.
Due to the benefits of this technique in identifying the root causes of errors, it can be used to prevent similar errors, eliminate organization defects, correct processes in the organization, and improve patient safety.