In the example in which there is a medication error, the hospital policy is to use root-cause analysis to fully evaluate the situation. In the root-cause analysis process, one would expect that:

Question

a. a committee is formed to determine the risk of litigation.
b. a committee is formed to determine the punishment for those involved.
c. a committee is formed that can reconstruct the events leading to the error.
d. a committee is formed that can correct the error and avoid damages.

Answer 1

C
In a root-cause analysis, a committee is formed, which in this case would include a facilitator (usually the risk manager or performance improvement director), the nurse or nurses involved, a pharmacist, the physician, and the team leader or supervisor. The purpose of the committee is to reconstruct the events leading up to the error. By looking at the process, the committee may dis-cover that the physician's order was unclear, that two drugs with similar names were placed next to each other in the medication-dispensing unit, or that the unit of measure for the drug was un-clear.