These steps are as follows:1. Define the problem (Hambleton, 2005). During this definition phase, investigators are able to determine the basis of the error – or the what, when, how, and why of the problem (Hambleton, 2005). In this case, the incorrect dosage of the drug is the what, when treatment in the emergency room is expected, and the how is simply a mistake made by the medical staff. However, the reason is still unknown.2. Develop a list of causes, major or minor, that could have led to the occurrence of the event that never occurred (Hambleton, 2005). During this phase, the incident will be broken down into causes and listed so that investigators can determine the underlying cause of the incident (Hambleton, 2005). By listing the causes, investigators can get a clearer picture of where the accident began. The staff failed to confirm the dosage amount? Was there a breakdown in communication between emergency room staff? Did the pharmacy make a mistake? Has the dosage/drug been checked by personnel subsequently involved in the patient's care? In other words, this discovery phase will alert investigators to the causes and their effects and determine the why or why