Don’t Bite the Hand That Feeds You
With adverse events, there is almost always a cascade in four phases: the trigger, the disabling agent, the disabling injury and the cause of death. Individually, each event is avoidable. Recognizing one at the time of occurrence is an opportunity to react and attempt to mitigate the risk before it becomes a problem. In root cause analysis of adverse events, the most significant factors are the lack of recognition and failure to react to the event.