Question

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle.

The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify?
(A) The nurse did not listen to the patient.
(B) The patient was male.
(C) The hierarchy in the operating room had a negative effect upon communication.
(D) In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one.

Answer 1

The surgical staff might identify the hierarchy in the operating room as a root cause of the wrong-site surgery incident.

Step-by-step explanation:

In this case, a root cause that the surgical staff might identify during the root cause analysis (RCA) is option (C) The hierarchy in the operating room had a negative effect upon communication.

The incident of a wrong-site surgery can often be attributed to breakdowns in communication and teamwork within the surgical team. In a hierarchical environment, where there may be a lack of open, effective communication, errors like wrong-site surgery can occur.

By identifying the hierarchy in the operating room as a root cause, the surgical staff can focus on improving the communication and teamwork dynamics to prevent similar incidents in the future.