A case's root cause analysis of osteofascial compartment syndrome induced by radial artery puncture and its defensive strategy

Objective

The objective of this study was to reduce or avoid the occurrence of the cases of osteofascial compartment syndrome induced by a radial artery puncture for arterial blood gas analysis.

Methods

We analyzed an adverse event using cheese model analysis, “fish bone” analysis, root cause analysis, and other methods.

Results

There are three root causes leading to an adverse event: operation technique, assessment of the disease, and informing patient families. However, there are many reasons to promote the occurrence and development of the event.

Conclusions

We should analyze and manage the adverse events in patients from the point of view of a system. Developing the measures of a system defense can enhance patient safety and create a good safety culture.