Root cause analysis of a case of transfusing wrong plasma
WU Jian-y · Zhonghua huli zazhi · 2013
Root cause analysis was conducted on a case of transfusing wrong plasma by using events description table,flowchart,control plan,etc. This method increased the logicality and consecution of the analysis process and revealed the root causes clearly,which can help nursing administrators to improve analyzing ability,identify the causes of the accident,then to propose proper improvement measures.