Using aggregate root cause analysis to improve patient safety.

The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.

Reducing medication confusion in homebound patients: when the data do not conform to the initial hypothesis.

Visiting nurses often find it difficult to reconcile multiple and conflicting medication orders, particularly when more than one physician orders medications. As the authors report, resolving medication order confusion was thought to be very time-consuming--until a team started to collect data.