Medical Error Analysis

Snapshot

• An academic medical center had 15 cases of adenovirus infection amongst patients on the medicine floor over the course of 2 weeks. An investigative committee performs a root cause analysis to determine the cause of this outbreak in hopes to prevent future outbreaks from recurring.

Root Cause Analysis (RCA)

• Definition
  • a problem solving method that focuses on finding the cause (the root) of a medical error in order to
    • identify preventative measures which are
      • subsequently implemented
• RCA attempts to answer
  • what happened?
  • why did it occur?
  • how can we prevent this from occuring again?
• This technique is applied after the medical error occurs to prevent it from recurring 

Failure Mode and Effects Analysis (FMEA)

• Definition
  • a technique used to evaluate risks in order to identify and eliminate
    • known failures
    • potential failures
    • systemic, design, process, and service issues
  • This technique is applied to prevent medical errors from occuring in the first place