Medical Direct/Root Cause Example 3 - Questions
{"Image DocumentName": "Medical Direct/Root Cause Example 3 - Questions?", "Image ImageDescription": "Sentinel event. Direct cause. Root cause - thoughts? Medication of Lasix drip hung to wrong patient. Patient had same last name. Interruption during medication administration. - nurse had very heavy patient assignment and skipped double check medication administration with another RN. Missed the double check process on patient identification and medication administration. All hospital medication should be double checked by two nurses. Direct Cause vs Root Cause INCOSE Chapter Meeting. March 14, 2007.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}