Internal and emergency medicine
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"Triage" is a useful tool used in emergency departments (EDs) to prioritize the care of patients. Through a methodical process of different sequential steps, the triage nurse assigns a color code which goes from red-critical patient with immediate access to medical examination-to a white code that represents no urgency. Clinical studies have shown that patients can be victims of errors during the process of care, especially in complex systems such as EDs. ⋯ We used a "root cause analysis" to explain an episode of missed recognition of red code at triage. A nurse without specific training in triage and inexperienced in critical care was identified as the "root cause" of the sentinel event. To make improvements we planned a triage training course (for newly employed nurses and a refresher course for existing staff) and created a team of dedicated triage nurses.