Abstract
In 2012, IP identified two cases of invasive Mucormycosis (mucor) isolated from respiratory and wound specimens. Both patients were located on different units adjacent to construction of a new bed building and resource center. Even after strengthening our Environment of Care (EOC) program there appeared to be blatant disregard for IP measures. An adapted version of The Human Factors Analysis and Classification System (HFACS) facilitated systematic identification, classification, and analysis of error causation.
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