A technologist performs a venipuncture for glucose testing on the wrong patient. This medical error leads to the patient receiving an incorrect dose of insulin and the patient goes into a coma--this medical error led to an adverse event.
Analysis without RCA:
- Determines the technologist should have checked the patient's wristband (the immediate reaction).
- Questions why the technologist did not also verbally identify the patient (the subsequent reaction).
- Restates these reactions (in the internal follow-up review).
- Misses causes discoverable by a detailed and open investigation.
Analysis with RCA:
- Includes descriptions of events leading up to a "wrong person procedure" in its reports.
- Describes 17 separate errors identified in the follow-up investigation.
- Recommends actions that should avoid reoccurrence of the error.
