As we on focus patient safety during this week, I thought it prudent to examine one of the more important aspects of providing a safe environment of care for our patients, the use of Root Cause Analysis (RCA) to prevent future events.  If we perform very thorough objective analysis, we can build corrective and preventative measures that will improve our systems and reduce or remove the chances for future similar events.

In the case study below, we’ll examine a medication error that affected one patient, could have affected two patients (due to swapped medications) but did not due to the quick response by the treatment team.  Learn to better analyze and create a safer environment for our patients, staff, and community.

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