Question

Make a Root Cause Analysis of the following case based on the guidelines established by the Joint Commission on Accreditation of Healthcare Organizations. Complete the table below and submit your answer as a “File Upload”.

Case Analysis

An 88-y.o. woman with dementia, a history of hypertension and coronary artery disease (post coronary artery bypass graft) was sent from her nursing home to the Emergency Department for worsening confusion. She had been admitted to the hospital six-weeks earlier and treated for urosepsis, at which time an allergy to levofloxacin was noted.

Initial evaluation revealed leukocytosis and pyuria, but no fever or flank pain. The ER doctor concluded that a urinary tract infection was the most likely cause of the patient’s altered mental status and elected to treat her with levofloxacin.

The first dose was administered on the medical floor shortly after the patient arrived. Over the next six hours, the patient became increasingly agitated and required sedation and restraint. She developed a diffuse erythematous rash.

1. What happened? Proximate Cause

2. Why did this happen? Contributing Factors

3. Risk reduction strategy. Action Plan.

Answer 1

1. The patient had urinary tract infection which did not get cured even after treatment. This led to systemic spread of infection and increased confusion. The patient had allergy to levofloxacin and administration of levofloxacin resulted in allergic reaction which caused increased agitation and diffuse erythematous rash.
2. The contributing factors were untreated urinary tract infection which resulted in sepsis, leucocytosis, pyuria and confusion.
As the patient was allergic to levofloxacin, administration of drug resulted in allergic reaction causing increased agitation and diffuse erythematous rash.
3. Risk reduction strategies include treating urinary tract infection and immediately stoping administration of levofloxacin.
Controlled hypertension and regular monitoring of blood pressure also help reduce the risk.
Moderate physical exercise, meditation, reduced intake of salt and taking balanced diet with green leafy vegetables help control stress and manage risks for cardiovascular diseases.