Authors

1. Ewen, Brenda M. RN, MSN, CPHRM
2. Combs, Rhonda RN-BC, MSN
3. Popelas, Carl Pharm D, BCOP
4. Faraone, Gail M. RN, MSN, CCM

Abstract

A home care patient received an unintended dose of 5-fluorouracil. This article details the agency's journey from error to the creation of a multidisciplinary collaboration to the implementation of statewide practice changes in an effort to improve patient safety.