Root Cause Analysis

[Faye Holmes]

I've been informed that I need to be at one and have never attended one before. Has someone ever been and what was the experience like?

[blondy2061h, MSN, RN]

Yep, I went to one for a very serious med error I made. It was a terrifying, but all in all very positive experience. No one was judgemental toward me, which was my biggest fear. I knew my manager, one physician I work with, and a pharmacist I work with. Everyone else was a stranger. We were all reminded at the beginning of the meeting that the goal was to prevent this from happening again, not place blame, and that most mistakes are systems failures. Even the mistake I made involved three different nurses before it was caught. I really appreciated being able to tell my side of the story, and they seemed to appreciate having someone there that could clarify details. It was a unique experience having excerpts of my charting from that shift layers out for critique. It's really changed how I think about charting.

In the end, we definitely made positive changes that have prevented the mistake from being repeated by anyone.