Conducting an RCA of a patient safety issue

Read the case study, The Wrong Patient, along with the supplemental RCA web links provided below, and discuss some of the specific changes that Mary would recommend being made to prevent such occurrences in the future.

Based on the reading of the case study and applying an understanding of RCA, assist Mary with identifying and explaining at least two issues in the case. Be sure to identify which type of factor each issue falls under, as outlined on the AHRQ website.

Next, offer at least two specific recommendations to improve the work processes described in the case. Mary should include in her discussion some of the barriers that she might expect in conducting an RCA of a patient safety issue such as the one presented in the case.