• Ann Emerg Med · Feb 2021

    Case Reports

    Errors in Decisionmaking in Emergency Medicine: The Case of the Landscaper's Back and Root Cause Analysis.

    • Kiersten Gurley, Jonathan Edlow, Jonathan L Burstein, and Shamai A Grossman.
    • Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
    • Ann Emerg Med. 2021 Feb 1; 77 (2): 203-209.

    AbstractRoot cause analysis is often suggested as a means of conducting quality assurance, but few physicians are familiar with the actual process. We describe a detailed approach to conducting root cause analysis, with an illustrative case to explain the technique. By studying how root cause analysis is applied to the case of a missed epidural abscess, the reader will see how the process reveals systems improvements that reduce the risk that such a miss will happen again. Following this process will be helpful in using root cause analysis to fix not just individuals' issues but also but systemwide quality assurance issues to improve patient care.Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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