Root Cause Analysis 3
the pulmonologist noted the completion of the left lung specimen collection because the images
aligned with the location that the pulmonologist had communicated. Since nobody else was
concerned about this he assumed it was correct. Since everyone had a specific task in the
procedure the error was not noticed because each assumed that everyone had performed their
tasks excellently including themselves.
However, during the probe after the procedure, the diagnostic radiology technician
decided to voice his earlier concern that the wrong lung had been operated on. Fortunately, the
procedure did not have any high-risk effect on the patient because it was only the retrieval of
specimens for examination. However, the team had wasted precious time and resources operating
in the wrong area. The examination was conducted on the right lung after readjusting the patient
correctly.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The adoption of the universal protocol for preventing wrong-site surgery was not
followed for this procedure. The most important strategy was to ensure that the correct surgical
site was identified and correctly marked on the patient. This should also be ensured by a pair of
clinicians involved in the procedure (Kung, Brook and Slanetz, 2016). The validation of this
information should be preferably done the night before the procedure to prevent any last-minute
rushes and panicking. It would also ensure that the patient has a chance for the patient to confirm
the details of the surgery.
The main priority of the clinic was to ensure that it develops a compulsory protocol.
Implementation of the protocol would ensure that the correct site for surgery is identified and
verified. This should be a collaborative effort for all staff members who include but are not

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Root-Cause Analysis and Safety Improvement Plan | NURS-FPX4020

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