a. Trace the path of the medication list and denote possible failure points. Construct a process
flowchart of the existing process and create a new chart of an improved process.
b. Was the medication error a failure of individuals or a failure of the process? Explain.
c. Think about the different settings: the ambulance, the emergency room, the hospital room,
and the nurse’s station. How is data handled in each setting? Can the process of recording
information be changed so that everyone is using the same data? How can the accuracy of
the data be assured?
d. Given Melanie’s reaction, do you think this error will happen again? Why or why not?