first Nursing Department of accountability. they bring up the most recent period from the computer records, found that Mary is responsible for regional patients increased 30%, while nurses are not increased. the investigation judge for the Department of nursing is not increased staffing at the right time, resulting in Mary's workload increased, overwork, deployment of personnel blunders.

counseling, Department of human resources and accountability bodies to investigate what's wrong with Mary's home recently. asks that, her child was two, just to go to kindergarten does not adapt, crying all night, affecting Mary rest in the evening. upon enquiry, the investigators concluded--psychologists in hospitals did not help her, failure!

final accountability pharmaceutical factory. experts believe, who do not want the wrong medicine, there may be cause of the drug itself. they mistake Mary the drugs together, found the appearance, color, very similar to several common drugs, very confusing. they sent letters to pharmaceutical firms, suggested common pill packaging, or change the shape of medicine, minimizing false positives on drug education for nurses.

those days Mary particularly nervous, do not know how the hospital will deal with mistakes in the job. the hospital psychologists made a special trip to visit her family, told her not to worry about patients compensation had been settled by the insurance company. and Mary spouses also explored how to care for a child and give her 10-hour volunteer help to the community. under Mary the night shift, volunteers with the baby to ensure she is able to get adequate rest. at the same time, hospitals special to her these days, period of the help her daughter through life in kindergarten.

after this incident, Mary is more careful, no similar errors. she and colleagues enjoyed his work, and always intended to do so.

we can see from this story, resulting in a part of the cause of the accident is absolutely not a single error. the "accountability" is a tracing mechanism, but we look at the powerful tools for system management capabilities. if we can manage to do a serious analysis of the problem not only see the tip of the iceberg, and more root causes is to sort out the problem completely, also will be able to fundamentally eliminate many anomalies and accidents happen.