Davoodi R (MD, MPH), Takbiri A ^* (MSc), Soltani Far A (MD, MPH), Rahmani S (MD), Hoseini T (MD), Sabouri G (MD), Ghoshkhanee H (MD), Darvish A (Medical Student)

  Research Center for Patient Safety, Mashhad University of Medical Sciences, Mashhad, Iran

  Received: 22 Sep 2012, Accepted: 23 Jun 2013

  Abstract

  Introduction: Medical errors threaten health and welfare of patients in health systems. Root cause analysis is an important way to identify errors and causes. This technique is a systematic analysis of cause and effect which tries to determine how patients’ issues, staff, policies, environments and processes are involved in occurrence of medical errors. The present study has analyzed root causes of an adverse event (death of a 21 year old patient who was admitted to hospital with abdominal pain) in Mashhad, 2011.

  Methods: This was a descriptive study conducted with qualitative approach within six steps. These steps included: defining the event, collecting the data, drawing causal factors, analyzing data and identifying root causes, and implementing recommendation. Root cause analysis was performed using tools such as brain storming and cause and effect diagram from August 2011 until October 2011.

  Results: Lack of immediate access to professionals and experts in different medical fields, unavailability of up-to-date guidelines, unawareness about CPR rules and insufficient number of ICU beds, inadequate personnel in push time, and lack of standard equipments for identifying and preventing risks were identified as causes of this medical error.

  Conclusion: Due to the usefulness of root cause analysis in patients' safety, this technique should be used systematically in health care providing unites for critical events management. Reporting and analyzing medical errors needs structural and cultural changes.

  Key words: medical error, root cause analyze, hospital, patient

  Please cite this article as follows:

 Davoodi R, Takbiri A, Soltani Far A, Rahmani S, Hoseini T, Sabouri G, et al . Root Cause Analysis of an Adverse Event in a Hospital in Mashhad, 2012: Case report. Hakim Research Journal 2013 16(2): 153- 158.

  * Corresponding Author: Research Center for Patient Safety, Imam Reza Hospital, Mashhad University of Medical Sciences, Taghi Abad square, Mashhad, Iran. Tel: +98- 511- 8521119, E-mail: takbiri2010@gmail.com