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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

ISMP Medication Safety Alert! Acute care edition. June 4, 2020;25(11).

Interventions to improve safety must include a range of tactics to ensure success. This article discusses how educational efforts alone will not reliably result in lasting change, human-centered weaknesses inherent in educational approaches and shares a model of overlapping actions required to generate sustainable system improvement.
ISMP Medication Safety Alert! Acute Care Edition. 2020;25.
Dose error-reduction systems (DERS) are standard functions in smart pumps. While they are designed to recognize dosing and programming errors, it has been observed that DERS are not fully utilized in operating rooms (OR). This article shares recommendations for addressing this medication safety gap including working with anesthesia providers and OR team members to establish use of DERS as an expected practice.