You are in charge of the risk management team that must investigate this incident and report to the CEO of the hospital. Based on what you have learned, list all the system failures that contributed to the patient safety event and discuss the following:

1. What was the event?
2. Who was involved?
3. Was there a process in place that might not have been followed that contributed or caused this event to take place?
4. Describe the project that you would assign to your quality improvement team to complete to prevent this from happening again.
5. Describe the project that you would assign to the health information management team to complete to prevent this from happening again.