Root Cause Analysis

Root cause analysis (RCA) is an approach that identifies the underlying issues that increase the chances of errors while keeping off the temptation of focusing on errors made by individuals (Gertler, Coralic, Lopez, Stein, & Sarkar, 2016). RCA is done to detect the active errors as well as the underlying problems in the system that contribute to the adverse events. Thus, this analysis is intended to prevent future harm by addressing the latent errors. In hospital setting, various factors may have a significant impact on the quality of care given to a patient. Information health technology has been implemented with the overall purpose of improving the health services accorded to patients. Furthermore, it also enhances the current health services provided in the hospital environment. Nevertheless, it has led to some employees losing their jobs since they lack the necessary knowledge and skills concerning the use of information technology in health care. Therefore, it is important that all employees in the hospital are adequately trained on the use of technology so that they were better equipped to handle issues that require technical know-how. The following case study is an incident that occurred at my place of work while I was on attachment.

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Case Study

I was on industrial attachment in one of the nearby hospitals. A patient had been admitted with a kidney disease. The doctor in charge of the patient was not well-versed with information technology despite the technology being available in use in the hospital. The doctor advised to give the patient a medication for stomachache. Upon being administered this medication, the patient felt worse and his condition deteriorated. He had to be referred to another hospital. At that time, I was just finishing the attachment and I had to report back to school. Because of this incident, I failed to get a letter of recommendation for good performance. The error that occurred was in the fact that the doctor had prescribed a medication that was not good for the patient. I was responsible for pushing the IV. The family transferred the patient to another hospital and as a result, a missed a recommendation for the school I wanted to get in. The whole issues began with a doctor, who was not willing to accept the new technology, and I was just a recipient of the ripple effect of the problem. This incident saddened me greatly. It was evident to me that several other patients could suffer from the effects of medication error if this problem were not addressed. I have had cases of patients losing their lives because of medication errors that could have been avoided had the practitioners embraced information technology.

Contributing Factors to the Incident (Why did It Happen?)

Patient safety and medication error are intertwined. Minimizing medication would translate to improvement in patient safety. The above scenario is a case of adverse drug event (ADE). The patient was given a wrong medication that was not good for kidney complication. The doctor was not well informed on the use of CPOE (computerized physician order entry) with decision support software. The system has key clinical variables that are used to calculate the risk profile, and it generates automatic recommendations that the physician can now follow or reject. The software also provides drug dosage depending on weight, clinical risks, and consensus guidelines. According to the doctor, the drug administered would help relieve the stomach pain that the patient was experiencing. However, he did not know that it would adversely affect the health status of the patient. The missing or weak step in this process was the lack of technical know-how on the implementation of information technology. The doctor did not have much information on how to handle the services that involved information systems.

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This problem resulted from the implementation of IT without preparing the human resource to operate such systems. It was apparent that the hospital had already installed information systems but it had not taken time to empower its employees on how to use the systems. This is why the doctor was reserved from using the system since he lacked the required knowledge to operate it.

Currently, the hospital works to have in-service training for all medical practitioners, particularly pharmacists, doctors, clinicians, and nurses. This will help monitor the operations at every level during the administration of any medication. More to say, the hospital also works on having capacity-building programs for doctors and nurses to improve their service delivery.

The doctor prescribed a wrong medication for the kidney patient and he was not ready to listen to my suggestions. I was forced to administer the drug against my wish, and this cost me my recommendation letter. The medication worsened the condition of the patient instead of improving it. As a result, the patient had to be referred to another hospital for further treatment.

The checking of contraindication was not done by the doctor as indicated in the policy (Panesar, Carson-Stevens, Salvilla, & Sheikh, 2015). The doctor was less qualified as he lacked efficient knowledge on application of IT in health care settings. He should have had prior knowledge on the impact of the medication on a kidney patient. The fact that he had prescribed stomachache medicine to a kidney patient raised doubts in the professional competence of the doctor. The hospital management will need to do more orientation and in-service training for the employees, particularly on the incorporation of ICT to hospital management. Additionally, there is the need for capacity building arrangement to boost the competence of the staff. Communication is vital among the hospital staff. Therefore, the error occurred because of inadequate sharing of information (Vincent, 2016).

The main cause of the medication error is the lack of proficient knowledge on the application of information technology in medication prescription. More to say, the hospital lacks adequate technological support for its staff that could assists in such a scenario. Consequently, the staff lacks flexibility in dealing with the situation that they seem to have privy knowledge about.

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Stomachache medicine disrupts the electrolyte balance in the body; thus, it can cause harm to a kidney patient. These medicines are meant to reduce pain by minimizing blood flow to the kidney, which ultimately affects the already malfunctioning kidney. The doctor did not consider the historical condition of the patient before prescribing such a medication. The use of CPOE with decision support software displays the contraindication of any medication that would be given to a particular patient. The policy on the actual implementation of CPOE at all levels in the hospital will help understand the condition of patient before administering any medication (Panesar, Carson-Stevens, Salvilla, & Sheikh, 2015).

Other environmental factor that may have contributed to the outcome is a busy schedule for the doctor. The doctor did not get time to go through the medical history of the patient and it was available in the system. He lacked the proper knowledge on accessing this information; thus, he worked on guesswork.


This paper has reviewed the case of medical error and identified root causes of it. These root causes were as follows. The doctor lacked the knowledge of the application of information technology in health care settings. Communication among the caregivers was only one way as I received the directives from the doctor but I did not get the chance to propose my views. Categories that apply to the case study include orientation and training of staff, communication among the hospital staff, the adequacy of technological support, and security systems and support.

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