Patient safety and risk management should be intertwined within the organization. Patient safety is when the patient experiences no harm, pain, or other unnecessary suffering during treatment (Youngberg, 2011). Minimizing risk means decreasing unnecessary losses or improving or implementing processes that will reduce adverse events (Youngberg, 2011). Samantha Jones' adverse event is a perfect example of how to improve patient safety through process or project improvement. To understand the event you need to perform a root analysis and from this analysis action items are created. Taking the time to conduct a proper cause analysis eliminates a premature conclusion that could lead to inadequate corrective actions (William, 2008). A root analysis is a systematic approach to gathering information that can identify and evaluate hazards and risks (Williams, 2008). Root analysis provides a starting point on areas that may need to be changed. There are three areas for adverse event root cause analysis that may allow the investigator to: 1) isolate the circumstances that increased the risk of an accident or incident occurring; 2) determine who or what was involved in the situation; and (3) evaluate whether the structure could have control over the causes of the event (William, 2008). Using a reporting framework can help gather consistency and completeness of information (Williams, 2008). The following scheme evaluates the adverse event of Samantha Jones.1. Policy or process (system) in which the event occurred:a. The policy or process did not confirm the correct patient. Nurses did not feel they could express their opinion on adequate time out. The time out was not conducted thoroughly2. Human resources (factors and issues)a. No......middle of paper......004). Root cause analysis applied to the investigation of serious and unpleasant incidents in mental health services. Retrieved from. http://pb.rcpsych.org/content/28/3/75.Parker, D. (2008). Managing risk in healthcare: understanding safety culture using the Manchester Patient Safety Framework (MaPSaF) Journal of Nursing Management; Mar2009, vol. 17 Issue 2, p218-222.Ransom, E.R., Joshi, M.S., Nash, D.B., & Ransom, S.B. (2008). The book of healthcare quality. (2nd ed.). Chicago, IL: Health Administration Press.Rooney, JJ and Vanden Heuvel, LN (2004) Root cause analysis for beginners. Extracted from. https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdfWilliams, L. (2008) The value of a root cause analysis. Long-Term Living: For Continuing Care Professionals, November 2008, Vol. 57 It is