It is my analysis that the root cause for the events to happen, in my example of a quality issue of the wrong site surgery, was a failure to follow multiple protocols of the organization. The World Health Organization has set a surgical safety checklist to help minimize the risk of this type of event (Hanchanale, Rao, Motiwala, & Karim, 2014). The hospital had multiple policies in place as well that were simply not followed. This was the last case of the day, on the day before Christmas Eve. I feel that played a great deal in the error. The staff was tired and ready to get home to start their holiday. However, the safety of the patient is the ultimate responsibility. Had the physician refused to start the surgery until he was absolutely
