Root cause analysis following nephrectomy after extracorporeal shockwave lithotripsy (ESWL)

Area of Science:

• Medical procedures
• Patient safety
• Quality improvement

Background:

• Extracorporeal shockwave lithotripsy (ESWL) is a common procedure for kidney stones.
• Adverse events, though rare, necessitate thorough investigation.
• Root cause analysis (RCA) is a systematic problem-solving method.

Observation:

• An unexpected adverse event occurred following a standard ESWL procedure.
• The event required immediate investigation to understand its origins.
• The clinical team initiated a root cause analysis to address the incident.

Findings:

• The root cause analysis methodology was applied to the ESWL adverse event.
• The process involved detailed examination of the procedure's steps and contributing factors.
• Specific causes leading to the adverse event were identified.

Implications:

• Implementing findings from the RCA can prevent future adverse events.
• This case study details the application of RCA in a clinical setting.
• Enhanced patient safety protocols can be developed based on RCA outcomes.