Using an Established Root Cause Analysis Framework to Evaluate an Unusual Allergen Immunotherapy Error

Abstract

RationaleA standardized root cause analysis (RCA) process can reveal the causes of immunotherapy errors.MethodsWe used the Joint Commission's published online “Framework for Conducting a RCA and Action Plan” tool to examine an unusual immunotherapy error that occurred at one of our immunotherapy mail out sites.ResultsA patient receiving immunotherapy at a mail-out site received 1000x the prescribed dose on two separate occasions and developed a systemic reaction to the second administration. The RCA entailed an in depth study in the following domains: human, equipment, controllable environmental, uncontrollable external, and other. The RCA identified potential sources of error in 4 out of the 5 domains. The RCA revealed that the most proximate source of error was that the nurse administered the wrong dose on two occasions by misreading written instructions. Further, the RCA revealed that for the human domain (new nurse unfamiliar with immunotherapy, nurse reluctant to call prescribing provider, and two additional nurses failed to identify the wrong doses), the equipment domain (written immunotherapy instructions confusing), the controllable environmental domain (no allergy immunotherapy training), and the uncontrollable external (low volume immunotherapy injections administered, 4-6 different sets of immunotherapy instructions) were likely contributing factors. As a result of the RCA, we implemented 4 major immunotherapy practice improvements in 4 domains.ConclusionsA formal RCA provided an effective framework for analysis and correction of immunotherapy errors. RationaleA standardized root cause analysis (RCA) process can reveal the causes of immunotherapy errors. A standardized root cause analysis (RCA) process can reveal the causes of immunotherapy errors. MethodsWe used the Joint Commission's published online “Framework for Conducting a RCA and Action Plan” tool to examine an unusual immunotherapy error that occurred at one of our immunotherapy mail out sites. We used the Joint Commission's published online “Framework for Conducting a RCA and Action Plan” tool to examine an unusual immunotherapy error that occurred at one of our immunotherapy mail out sites. ResultsA patient receiving immunotherapy at a mail-out site received 1000x the prescribed dose on two separate occasions and developed a systemic reaction to the second administration. The RCA entailed an in depth study in the following domains: human, equipment, controllable environmental, uncontrollable external, and other. The RCA identified potential sources of error in 4 out of the 5 domains. The RCA revealed that the most proximate source of error was that the nurse administered the wrong dose on two occasions by misreading written instructions. Further, the RCA revealed that for the human domain (new nurse unfamiliar with immunotherapy, nurse reluctant to call prescribing provider, and two additional nurses failed to identify the wrong doses), the equipment domain (written immunotherapy instructions confusing), the controllable environmental domain (no allergy immunotherapy training), and the uncontrollable external (low volume immunotherapy injections administered, 4-6 different sets of immunotherapy instructions) were likely contributing factors. As a result of the RCA, we implemented 4 major immunotherapy practice improvements in 4 domains. A patient receiving immunotherapy at a mail-out site received 1000x the prescribed dose on two separate occasions and developed a systemic reaction to the second administration. The RCA entailed an in depth study in the following domains: human, equipment, controllable environmental, uncontrollable external, and other. The RCA identified potential sources of error in 4 out of the 5 domains. The RCA revealed that the most proximate source of error was that the nurse administered the wrong dose on two occasions by misreading written instructions. Further, the RCA revealed that for the human domain (new nurse unfamiliar with immunotherapy, nurse reluctant to call prescribing provider, and two additional nurses failed to identify the wrong doses), the equipment domain (written immunotherapy instructions confusing), the controllable environmental domain (no allergy immunotherapy training), and the uncontrollable external (low volume immunotherapy injections administered, 4-6 different sets of immunotherapy instructions) were likely contributing factors. As a result of the RCA, we implemented 4 major immunotherapy practice improvements in 4 domains. ConclusionsA formal RCA provided an effective framework for analysis and correction of immunotherapy errors. A formal RCA provided an effective framework for analysis and correction of immunotherapy errors.