Imagine you are the manager of a large 60-bed medical surgical three-floor unit. A patient has died from a medication error, the nurse administered insulin to a patient who was not a diabetic and the reaction led to the patients' eventual death. In this situation you know the patient is dead as a direct result of the nurse's error but...what happened in the system to cause this error to occur?

Based on this scenario what questions would you ask and seek answers to in a root cause analysis of this scenario?

PLEASE GIVE ME A REFERENCE