Sorry, you need to enable JavaScript to visit this website.
Skip to main content
Study

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.

Save
Print
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. Saf Sci. 2010;49(1).
View more articles from the same authors.

This case study examines an organizational response to a serious adverse event—a medication error in the intensive care unit that caused serious patient harm. Although a root cause analysis (RCA) was eventually convened, resulting in implementation of a systematic solution, prior to the RCA each professional group involved (nurses, pharmacists, and physicians) had already decided on individual approaches and solutions to the error. This resulted in unnecessary conflict and delays in reaching a workable solution to the problem.

Save
Print
Cite
Citation

Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.

Related Resources From the Same Author(s)
Related Resources