Which quality tool is most appropriate for reviewing an incident where a patient received ten times the recommended ACLS dose of epinephrine?

The most appropriate quality tool for reviewing an incident where a patient received ten times the recommended ACLS dose of epinephrine is root cause analysis. This method is specifically designed to systematically investigate adverse events and understand the underlying factors that contribute to such occurrences.

Root cause analysis not only focuses on identifying the immediate cause of an error but also explores broader systemic issues and contributing factors. In this scenario, the severity of administering ten times the recommended dose indicates a critical need to uncover not only what went wrong but why it happened, including potential issues related to communication, protocol adherence, training, or other systemic failures.

While healthcare failure mode and effect analysis is useful in assessing risks and potential failures before an incident occurs, it is more proactive and aimed at preventing future issues rather than investigating a past event. Gap analysis examines the difference between the current state and desired performance, which may not provide the depth of insight needed after such a serious incident. Medication use evaluation focuses on the appropriateness and outcomes of medication use but does not delve into the mechanisms behind a specific incident.

Selecting root cause analysis facilitates a thorough exploration into the complexities of medication errors, aiming to develop effective strategies to prevent similar occurrences in the future.