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Root Cause Analysis: Medication Error

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Published on May 4, 2012

Presenters:
Robert J. Latino, CEO. Reliability Center, Inc.
Beth Boynton, RN, MS


Summary:
This medication error took place on a 20 bed Dementia unit staffed with 1 RN and 2 LNA's. An error was found at the end of the nurse's shift when the narcotics count showed an extra Clonazepam and a missing Lorazepam. No harm was done to the patient. This RCA analyzes the incident in-depth and demonstrates how much can be missed by using the 'typical" incident report, thus increasing the risk of recurrence.
Download the RCA Tree Here: http://www.reliability.com/confidentv...
VISIT RCI TO LEARN MORE: http://www.reliability.com
Reliability Center, Inc. Info@Reliability.com
Root Cause Analysis Training, Consulting & Software for Healthcare & Industry

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