Updated: 2/12/2018

Medical Error Analysis

Review Topic
  • 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

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