Root-Cause Analysis of an Adverse Drug Reaction and Safety Improvement Plan (Essay Sample)

Root-Cause Analysis and Safety Improvement Plan
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Root-Cause Analysis
Medical errors are rarely unheard of in any clinical setting. Occasionally medical errors occur because of negligence. However, the majority are a consequence of adverse events or sentinel events in healthcare. The case for review is an adverse event that occurred to Mrs. M at a local facility following medication to manage her convulsive disorder. After successful treatment at the emergency department, she went home with antiepileptic medication. She later presented with a cutaneous skin reaction. The paper is a root-cause analysis of the adverse event that required readmission of the patient following the antiepileptic medication.  
Analysis of the Root Cause
The incident that transpired at the local facility was an adverse drug reaction to a patient after the prescription of antiepileptic medication. The patient had presented with a history of seizures. She received a dose of phenytoin to control the convulsions and was discharged on oral drugs, carbamazepine, and lamotrigine. Three days later, Mrs. M presented with a cutaneous drug reaction. She denied any prior use of anticonvulsants or adverse medication following the use of any drug. A review by the dermatologist revealed that she likely suffered an adverse drug reaction, Steven Johnson Syndrome. Her condition