What Are the Root Causes?
● Pharmacies conduct their own investigations on their own employees. ● Labs conduct their own investigations on their own employees. ● Radiology labs investigate their own employees. ● Operating rooms investigate their own employees. ● Nurses investigate their own employees. ● Cardiologists investigate their own employees.
What Can One Do About It?
Create a non-punitive environment, form multidisciplinary teams, invite subject-matter experts and process owners to the table, and discuss all patient safety issues. Make the discussion a learning experience, with the focus on preventing adverse events in your facility.