In a situation involving a medication error, the hospital policy is to use root-cause analysis to evaluate the situation fully. In the root-cause analysis process, which action would take place?

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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 discover 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 unclear.

In a Situation Involving a Medication Error, the Hospital Policy