Root Cause Analysis of Preventable Limb Loss and Subsequent Death After Arteriogram: Improved Focused Nursing Education and System Processes

• Improving focused nursing education increases a patient's chance for best outcomes.
• The nurse has duty to the patient to provide standard of care and can be held liable.
• The health care system is accountable for system processes and staff performance.
• Implementation of a consistent patient care process increases best patient care.

The purpose of this article is to identify, by root cause analysis (RCA), the contributory factors in patient care leading to limb loss with subsequent death after elective arteriogram. A case study demonstrating a system failure and the ensuing action plans are presented. This RCA identifies inadequacies displayed in the nursing process and a breach of duty, specifically during the nursing assessment. Competency, communication, and compliance were reviewed as well during this investigative process, and necessary revisions were made. Mandatory nursing education and training were implemented regarding vascular anatomy, intravascular procedures occurring in interventional radiology, and neurovascular assessment after lower extremity arteriogram. Policies were standardized involving specific hospital units caring for postintravascular procedure patients. As evidenced in this sentinel event, negligent acts can occur without the utilization of appropriate and complete nursing processes.