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  1. Ewen, Brenda M. RN, MSN, CPHRM
  2. Combs, Rhonda RN-BC, MSN
  3. Popelas, Carl Pharm D, BCOP
  4. Faraone, Gail M. RN, MSN, CCM


A home care patient received an unintended dose of 5-fluorouracil. This article details the agency's journey from error to the creation of a multidisciplinary collaboration to the implementation of statewide practice changes in an effort to improve patient safety.