Latest / Lean Blog by Mark Graban
When “Human Error” Is the Root Cause, the Investigation Stopped Early
Tennessee regulators released an eighty-page report this week on the medication error at Ascension Saint Thomas Midtown in Nashville, where four patients scheduled for routine joint replacement were injected in the spine with potassium phosphate instead of an anesthetic. Two are paralyzed. One remains on ECMO. I wrote about the case when it broke and updated that post with what the report found. The report is said to name human error as the primary cause. […] The post When “Human Error” Is the Root Cause, the Investigation Stopped Early by Mark Graban appeared first at Lean…
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