Here is an example, based on a dental adverse event case, that will help to demonstrate how we went about conducting Root Cause Analysis. We will be using the step-wise approach from the previous page, combined with the RCA methods mentioned earlier.

Case:

“Tooth number 22 is surgically extracted on a patient with a coronary stent at an academic institution.

Three days after extraction, patient returns and presents with a large hematoma, swelling and pain in left cheek but dental providers advise it to be part of normal healing process.

Four days later, patient returns once again with continued swelling, bruising and pain.

Delayed healing and presence of a left mandibular and cheek hematoma prompts providers to obtain a medical consult. It was at this point that the providers discovered that the patient is on an anticoagulant therapy and has been prescribed with a combination of Aspirin and Coumadin. The latest bloodwork revealed an INR value > 7.0.”

For this example, an inductive approach was achieved with the Five-whys technique and Fish-bone analysis was used for the deductive approach.

Step 1: Forming a team

In this case, as the incident happened at an academic institution, two dental faculty members, a dental student, and one member of the quality assurance committee may form the team. However, as mentioned earlier, if the AE occurred at a dental office with a small number of providers and staff members, RCA can be performed by a single person or a small team made up of two members.

Step 2: Identifying the Adverse Event and describing the problem

The problem statements for this case can be:

A surgical extraction was performed on a patient with a coronary stent. The patient did not mention that he is receiving anticoagulant therapy and has been prescribed a combination of Aspirin and Coumadin.
The dental providers relied on the information given by the patient and performed a surgical extraction without obtaining a medical clearance, as per the guidelines of the American Heart Association.
After the surgical extraction, the patient developed a large hematoma and swelling in his left cheek, putting him at risk for infection and caused him prolonged pain.

Step 3: Data gathering and Information seeking to describe the system, event and consequences

We used the RCA template developed by us, for this step. Below is the filled template based on the information available for this case.

Trigger:
AE: Soft Tissue Injury
Severity grade: E2
Medical Alerts:
Age:

Date of Adverse Event: Type of AE:	MM/DD/YYYY Soft Tissue Injury
How was it detected?	Patient complaint Detected by provider or staff Patient notes review Incident report
What happened? Provide a preliminary narrative of the event.
Patient gender:	Male Female
Patient Age:
Medical History:	Thorough Review: Yes No Significant findings:
Dental History:	Thorough Review: Yes No Significant findings:
Periodontal status:	Significant for this case: Yes No
Radiographic Evidence:	Significant for this case: Yes No Findings:

Relevant radiographs:
Other relevant findings:

Step 4: Choose appropriate RCA methods

In this case, we applied the deductive approach as this was a retrospective analysis and our only source of data was EHR documentation.

Step 5a: Identify possible contributing Factors

The sequence of events in chronological order:

Ideal sequence of events:

Examples of factors likely to have contributed to the development of hematoma due to inadequate risk assessment and lack of maintaining communication with the patient’s physician prior to surgical procedure could have been:

Provider factors:
- Didn’t follow the guidelines of the American Heart Association to get a medical clearance.
- Provided treatment based on information given by the patient and didn’t investigate further.
Patient factors:
- Patient did not mention his anticoagulant therapy to the dental provider.
Organizational Factors:
- There was no shared decision making and care coordination.
- No checklist or time-out was required or requested before a surgical procedure.

Fishbone Diagram for this case:

Step 5b: Identify the Root causes of the Adverse Event

Five-whys method for this case:

Causal Tree Map for this case:

Step 6: Develop and implement strategies to prevent future dental Adverse Events

Examples of strategies that may prevent an occurrence like the one summarized in this case (patient who developed a hematoma after a surgical extraction of tooth) may be:

Strategy 1.

Patients with a coronary stent may be undergoing anticoagulant treatment. As part of our risk assessment, prior to a surgical procedure, all patients with a coronary stent will have to receive medical clearance from their physician prior to treatment. We will maintain a close communication with the patient’s physician to confirm medical conditions and medications received.

Strategy 2.

To provide safe and successful patient care, portable coagulometers devices will be utilized for in-house INR analysis the day of the surgical procedure. Studies have shown that these devices are accurate, reliable and results are consistent with conventional laboratory values.