The Case of the 10 Pound Giant: A Near Miss Root Cause Analysis

Authors

Debbie Chen, MD, Thomas Jefferson University HospitalFollow
Megan Margiotta, MD, Thomas Jefferson University HospitalFollow
Grant Turner, MD, Thomas Jefferson University HospitalFollow

Files

Description

Objectives:

Through an Interprofessional Root Cause Analysis of this Near Miss event, we aimed to: 1.Identify issues contributing to the incorrect dosing of acyclovir 2.Understand relevant institutional policies and compare this to usual practice 3.Propose possible solutions

Publication Date

5-31-2017

Keywords

The Case of the 10 Pound Giant: A Near Miss Root Cause Analysis

Disciplines

Medicine and Health Sciences

Recommended Citation

Chen, MD, Debbie; Margiotta, MD, Megan; and Turner, MD, Grant, "The Case of the 10 Pound Giant: A Near Miss Root Cause Analysis" (2017). House Staff Quality Improvement and Patient Safety Conference (2016-2019). Poster 24.
https://jdc.jefferson.edu/patientsafetyposters/24