INSTRUCTION:

Read the Multifactorial Medication Mishap case study and the commentary that follows.

Link to article: https://psnet.ahrq.gov/webmm/case/314/multifactorial-medication-mishap

Complete the root cause analysis worksheet to analyze the case.

Write a 525 word-summary in which you:

  • Explain why a root cause analysis was appropriate for this situation.
  • Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.

Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.

Submit your worksheet and summary.

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