In the case study, identify the incident and explain the problem that could trigger a root cause analysis. In this case study, a patient admitted to the intensive care unit (ICU) with septic shock requiring vasopressors suffered an MI during treatment due to vasopressin overdose during the incident. The issue that triggered a root cause analysis was likely related to a logarithmic increase in vasopressin dose due to a prescription error. Pharmacy issues also figured prominently in this error, as the computerized physician order entry (CPOE) system did not eliminate medication errors. and a domino effect for the nurse who initiated the treatment that ultimately caused the patient to have an MI. The patient in this case was receiving the drug vasopressin, at a dose of 0.4 units/min, a dose used for gastrointestinal bleeding and variceal bleeding rather than the correct dose of 0.04 units/min to treat shock . The vasopressin order was written incorrectly by a resident physician after receiving a verbal order from his fellow ICU supervisor (Flanders, S. & Saint, S., 2005). The dose used for the patient was so high that it acted as a vasoconstrictor agent to reduce blood flow and facilitate the formation of hemostatic plugs in the bleeding vessel, thereby causing MI (complication of high dose vasopresson infusion ) (Cagir, B. & Katz, J.). Additionally, the nurse caring for this patient administered an incorrect dose of vasopressin due to a domino effect. In fact, the incorrect dose was administered for more than 16 hours, meaning more than one nurse was involved in the error. It was only when a nurse discussed medication dosing with nursing students that the wrong...... middle of document...... Root cause analysis in response to a sentinel event. Accessed March 2014 from the web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdfOrlando Regional Healthcare, Education & Development. (2004). Patient safety: preventing medical errors. Accessed March 2014 from the web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdfScott,DM,A. (May 31, 2011). How to fill out an incident report. Retrieved March 2014 from YouTube at https://www.youtube.com/watch?v=-MRJUC6HgzQWebMD. (2005-2014). Heart Disease Health Center. Retrieved March 2014 from the World Wide Web at http://www.webmd.com/heart-disease/guide/heart-disease-heart-attacksWolf, Zane Robinson & Hughes, Ronda G (nd). Error reporting and disclosure. Retrieved March 2014 from the World Wide Web at http://www.ncbi.nlm.nih.gov/books/NBK2652