Patient safety and risk management must be closely linked within the organization. Patient safety means that the patient does not experience unnecessary harm, pain, or other suffering during treatment (Youngberg, 2011). Minimizing risk involves reducing unnecessary losses or improving or implementing a process that will reduce adverse events (Youngberg, 2011). The Samantha Jones adverse event is a perfect example of improving patient safety through an improved process or project. To understand the event, fundamental analysis must be performed and action steps are created from this analysis. Taking the time to conduct a proper cause analysis eliminates a premature conclusion that could lead to inadequate corrective action (William, 2008). A root analysis is a systematic approach to collecting information to identify and assess hazards and risks (Williams, 2008). Fundamental analysis provides a starting point on areas that might need change. Root cause analysis of an adverse event has three areas that can allow the investigator to: 1) isolate the circumstances that increased the risk of an accident or incident; 2) determine who or what was involved in the situation; and (3) assess whether the establishment could have control over the causes of the event (William, 2008). Using a reporting plan can help ensure consistency and completeness of information (Williams, 2008). The plan below evaluates Samantha Jones' adverse event.1. Policy or process (system) in which the event occurred:a. The policy or process did not confirm the correct patient. The nurses did not feel they could express their opinion on the appropriate discharge time. Time-out was not carried out thoroughly2. Human resources (factors and issues)a. No...... middle of paper ......004). Root cause analysis applied to investigations of serious and untoward incidents in mental health services. Retrieved from. http://pb.rcpsych.org/content/28/3/75.Parker, D. (2008). Risk Management in Healthcare: Understanding Your Safety Culture Using the Manchester Patient Safety Framework (MaPSaF) Journal of Nursing Management; March 2009, vol. 17 Number 2, p218-222. Ransom, ER, Joshi, MS, Nash, DB, & Ransom, SB (2008). The quality of care book. (2nd ed.). Chicago, IL: Health Administration Press. Rooney, JJ and Vanden Heuvel, LN (2004) Root Cause Analysis for Beginners. Retrieved from. https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdfWilliams, L. (2008) The value of root cause analysis. Long-term life: For the continuing care professional, November 2008, vol. 57 East