Simulated Root Cause Analysis
Cases
Case Summary: A patient was admitted with a new diagnosis of metastatic lung cancer. Had a chest x-ray showing a lung nodule 6 months ago while in cardiology clinic. Chest x-ray does not appear to have been followed up.
Audience: Emergency Medicine, Inpatient/Outpatient Internal Medicine, Family Medicine, Critical Care, Nursing, Pharmacy
Case 2 mystery of the misdosed medicine
This case is available on MedEd Portal and we encourage you to see their website for full case access. It is no longer available through this site.
Case Summary: Following an ICU consult, a patient in the Emergency Department was given the incorrect route of administration for epinephrine to treat anaphylaxis. This lead to cardiac arrhythmia, seizure, and ICU admission.
Audience: Emergency medicine, Inpatient Internal medicine, Critical Care, Nursing, Pharmacy
Case Summary: A patient was scheduled for vascular surgery on his left leg. He was called down to pre-operative area by the Post-Anesthesia Care Unit nurse on the day of his procedure. He was sedated and intubated before anesthesia discovered his procedure was cancelled by the surgery team.
Audience: Surgery & Surgical Subspecialties, Anesthesiology, Pre/Post-Operative Care Nursing, Registration/Front Desk
Case Summary: Results of critical value of anemia and abnormal transvaginal ultrasound from clinic not available in chart for review by ED. Patient care was delayed, required transfusion and treatment for sepsis after missed ectopic pregnancy.
Audience: OB/GYN, Family Medicine, Outpatient Internal Medicine, Emergency Medicine, Laboratory Technician/Pathology, Registration, Information Technology
Case Summary: Case 5 uses the same error and structure as Case 4 The Mystery of the Multiplied Medical Record. However this version focuses on how social and structural risk factors made the system more likely to fail this patient.
Audience: Recommended for anyone. Specifically includes OB/GYN, Family Medicine, Internal Medicine, Emergency Medicine, Laboratory Technician/Pathology, Registration, Information Technology.