Root Cause Analysis Gone Wrong
For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney. In the commentary, Mohammad Farhad Peerally, MBChB, MRCP, of the University of Leicester, and Mary Dixon-Woods, DPhil, of the University of Cambridge, describe weaknesses associated with root cause analysis in health care and emphasize the importance of establishing a safety culture fostering open dialogue about medical errors to maximize organizational learning.