By: Lawrence F Muscarella, PhD; updated: 10/29/2014: The article “Other Possible Causes of a Well-Publicized Outbreak of Pseudomonas aeruginosa Following Arthroscopy in Texas” by Lawrence F Muscarella, PhD, was published in the June, 2013, issue of the peer-reviewed medical journal Advances in Infectious Disease.

This article provide rare insight into how a root cause analysis can be used to provide recommendations to prevent medical errors and as a general tool of continuous healthcare improvement.

Root cause analysis

According to Wikipedia, “root cause analysis,” or RCA, is a method that, generally speaking, aims to prevent the recurrence of an encountered error – such as an identified medical error or a healthcare-associated bacterial outbreak – “by attempting to identify and correct the root causes of events, as opposed to simply addressing their symptoms.”

Example, application

An example of a root cause analysis (RCA) that aims to prevent a bacterial outbreak’s recurrence through the identification of all of the outbreak’s possible causes is provided in Table 4 of Dr. Muscarella’s aforementioned published article (in Advances in Infectious Disease). 

Click here to learn about Dr. Muscarella’s program designed to help medical facilities manage and reduce risk and improve both quality and patient safety.

More specifically, Table 4:

  1. identifies the adverse medical event – namely, an outbreak (five infections) of Pseudomonas aeruginosa following arthroscopy of the shoulder and knee;
  2. lists several deviations that were found during this outbreak’s investigation to be associated with this bacterial outbreak;
  3. provides the concern associated with each of these identified deviations;
  4. lists some of the likely causes and/or factors that contributed to each of these identified deviations;
  5. features the corrective actions and/or risk-reducing strategies that correspond to each of the likely causes and/or contributing factors referred to in #4, above; and
  6. provides the measures or steps that were employed to ensure (or validate) the effectiveness of each of these corrective actions or risk reducing strategies referred to in #5, above, for the prevention of each corresponding deviation and, therefore, of the outbreak’s recurrence.

Article, Table 4

  • Click here to obtain a copy of Dr. Muscarella’s article, which includes Table 4.
  • Specifically, this link will provide the abstract of the article.
  • Once there, click the displayed red “PDF” link
  • This will provide the visitor with a free copy of this complete article.


In addition to a root cause analysis (RCA) of an outbreak of Pseudomonas aeruginosa that was identified in 2009 following arthroscopic procedures performed at a hospital in Texas, Dr. Muscarella’s article provides a comprehensive review of the details and conclusions of this outbreak’s investigation, which was performed by, among others, the Centers for Disease Control and Prevention (CDC).

Click here to learn about Dr. Muscarella’s program designed to help medical facilities manage and reduce risk and improve both quality and patient safety.


The CDC’s published investigation that Dr. Muscarella’s article reviews is referred to as the Tosh et al. (2011) study, and it can be read by clicking here.

NBC Nightly News

NBC Nightly News produced a report about this outbreak in Texas in 2009. Click here to view a video of this NBC report.

But, did NBC get it right? Were dirty surgical instruments the most likely cause of this bacterial outbreak? Might another unrecognized factor have been more responsible for this bacterial outbreak in 2009?

Read Dr. Muscarella’s article for insight into the answers to these questions.

The Center for Public Integrity

Similarly, The Center for Public Integrity wrote a popular report about this outbreak. Click here to read its article entitled “Filthy surgical instruments: The hidden threat in America’s operating rooms.

Food and Drug Administration (FDA)

In response to this bacterial outbreak in Texas, the Food and Drug Administration (FDA) published a statement entitled, “Ongoing Safety Review of Arthroscopic Shavers.”

It is recommended that this article be read in conjunction with another of Dr. Muscarella’s — click here to read this second article, which discusses a study that evaluated the effectiveness of steam sterilization in the presence of hydraulic fluid.


Dr. Muscarella is an independent infection-prevention consultant.

Click here to read a brochure that describes a number of his services, including performing root cause analyses (and/or risk assessments) of infection-control breaches (or of other adverse medical events) identified in a GI endoscopy department or another healthcare setting.

By: Lawrence F Muscarella PhD, posted 6-14-2013; updated 10/29/2014, Rev A.

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