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PSNet: Patient Safety Network
Journal Article

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

Tamuz M, Franchois KE, Thomas EJ. Safety Science. 2010;49.

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.