· Briefly summarize the patient safety risk you have selected, and provide a rationale for why it deserves particular attention.

· Analyze the influence of systems errors and human factors errors with regard to this risk.

· Discuss related insights that could be gained from high-reliability organizations and how they might be applied within a health care organization.

· Propose strategies and tools for assessing and reducing risk related to this safety issue.

· Describe how patients and patients' families can be involved in addressing this issue.