May 27, 2010 | Mark Paradies

Mother Dies at UK NHS Hopital After Injection of Wrong Drug

The story printed in SHP said that:

“HSE investigators discovered that the two drugs were stored in the same racking system, despite having almost identical packaging. They found that no proper management system was in place for the storage of the drugs, and warnings from earlier incidents had not been properly followed up.”

The story said that the mother had died needlessly.

What do you do to make sure that your root cause analysis and corrective actions for incidents are effective?

Would your facility have a “needless” death?

Should you be using TapRooT® and attending the TapRooT® Summit to learn ways to check the effectiveness of your root cause analyses and corrective actions?

Things to think about…

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