Interviewer for Cardiology fellow:
First Question: As a member of the root cause analysis team, we are trying to understand the system issues that led to errors in Mr. Bridges care. Can you start by telling me about the case from your perspective?
And wait for interviewee to respond
Second Question: Well I’m glad the patient ended up doing well and didn’t have any long-term complications. Do you have any insight on the communication with the nephrology team earlier in the day before he was transferred to the MICU?
Interviewer for ICU fellow
First Question: I’m trying to better what happened the night Mr. Bridges was admitted to the ICU. It seems like there was a delay in his HD orders. Can you tell what you remember about your team’s communications with the nephrology team?
And wait for interviewee to respond
Second Question: Thank you for clarifying that. Do you recall who reached out to the nephrology team the second time?
Interviewer for nephrology attending
First Question: Our RCA team is trying to get a better understanding of the events of this case. I think it’s important to point out that the purpose of our team is not to assign blame to the providers involved in the case, but rather to learn about any issues with how our hospital system delivers care that could be improved to prevent future medication errors. Can you tell me about your understanding of this case?
And wait for interviewee to respond
Second Question: Seems like the patient ultimately got the care they needed. What do you think as a attending could be done to prevent an error like this happening again in the future?
Interviewer for pharmacist
First Question: As a member of the RCA team we are trying to get a better understanding of the events of this case. Can you tell me about your perspective of this patient’s care?
And wait for interviewee to respond
Second Question: That can definitely make it hard. In the current process, do you have to override the order if a lab value like creatinine is abnormal?