Following an adverse event involving a PA, what sequence aligns with risk management best practice?

• A. Blame the PA
• B. Review the event, implement corrective actions, monitor outcomes
• C. Ignore the event
• D. Increase penalties

Answer: (B)

A systematic, non-punitive approach to patient safety emphasizes learning from incidents to prevent recurrence. The best sequence starts with reviewing the event to understand exactly what happened, what factors contributed, and where the system failed. Next, implement corrective actions aimed at addressing those root causes—this may involve changes to workflows, policies, training, or technology. Finally, monitor the outcomes to verify that the changes reduce risk, measure improvement, and adjust as needed. This fosters a learning culture and continuous improvement.

Blaming the PA discourages reporting and learning from errors, ignoring the event misses opportunities for safety improvements, and increasing penalties is punitive and unlikely to reduce future risks.