As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.For this Assignment, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.

The Assignment: (3–4 pages)

  • Briefly summarize the salient facts of the New York Times article.
  • Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
  • Qualitatively assess how much each factor contributed to the error.
  • Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.

By The New York Times

A Tampa surgeon who has been widely vilified and ridiculed for mistakenly amputating the wrong leg of a patient on Feb. 20 sought this week to regain both his license to practice medicine and a measure of his once-solid reputation.

In a three-day hearing before the state official who will make recommendations on his professional future, the surgeon, Dr. Rolando R. Sanchez, and his lawyer, Michael Blazicek, publicly presented their side of the story for the first time.

They said that a series of errors by other hospital personnel and the severely diseased condition of both legs led Dr. Sanchez to believe that he was operating on the correct leg.

The blackboard to which surgeons refer in the operating room at University Community Hospital in Tampa listed the wrong leg for amputation, as did the operating room schedule and the hospital computer system, testimony revealed. By the time Dr. Sanchez entered the operating room, the wrong leg had been sterilized and draped for surgery.

Some doctors who appeared as witnesses said that the leg Dr. Sanchez removed was in such poor shape that it would probably have been amputated in the future.

“It is my opinion that 50 — no, probably 90 percent — of the surgeons in this state would have made the same mistake that Dr. Sanchez made,” said Dr. Joseph Diaco, an expert witness for the defense who is a surgeon and teacher at the University of South Florida. Even a witness for the state suggested it was a mistake anyone could have made.

But Steven A. Rothenburg, the lawyer pressing the case against Dr. Sanchez for the Florida Agency for Health Care Administration, said that the surgeon should have checked other paperwork, including the patient’s consent form and medical history, both of which were available in the operating room.

“Isn’t it true,” he asked Dr. Diaco, “that Dr. Sanchez had the last clear chance before he picked up that knife and cut into that tissue” to make certain the correct leg was being removed?

Dr. Diaco said it was true.

Dr. Sanchez testified that he learned of his error from a nurse as he was still cutting through the leg of the patient, Willie King, 52. After reviewing the patient’s file, she had started to shake and cry. But by that point, he said, there was no turning back. “I tried to recover from the sinking feeling I had,” he testified, as his eyes grew moist and his voice trailed off.

In July, the state’s health agency suspended the medical license of Dr. Sanchez, who will be 51 this month, claiming he presented an “immediate and serious danger to the health, safety and welfare of the public.”

That order was issued after another patient of Dr. Sanchez, whom he had treated at another Tampa hospital, Town and Country, said that she had not given him permission to amputate a toe during a procedure to remove diseased tissue from her right foot.


Root Cause Analysis

September 7, 2019


Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now 
widely deployed
 as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the 
systems approach
 to identify both 
active errors
 (errors occurring at the point of interface between humans and a complex system) and 
latent errors
 (the hidden problems within health care systems that contribute to adverse events). It is one of the most widely used retrospective methods for 
detecting safety hazards

RCAs should generally follow a prespecified 
 that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then 
 the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors) (Table). The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events.

Table. Factors That May Lead to Latent Errors

Type of Factor



A patient on anticoagulants 
received an intramuscular pneumococcal vaccination
, resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.


A nurse