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Lesson from Colorado. Beyond blaming individuals

J L Smetzer¹

¹Institute for Safe Medication Practice, Warminster, Pa., USA.

Nursing Management

|November 10, 1998

Summary

A medication error tragically caused a newborn

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Medication errors: integrating individual and system accountability.

American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists·1999

Same author

Lesson from Colorado. Beyond blaming individuals.

Nursing·1998

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Area of Science:

Medical error analysis
Patient safety in healthcare

Background:

A fatal medication error involving a newborn
Criminal charges filed against healthcare professionals

Framework:

Step-by-step analysis of the incident
Identification of systemic vulnerabilities

Implementation:

Review of medication administration protocols
Assessment of nursing workflow and oversight

Implications:

Preventing future patient harm
Improving healthcare system safety and accountability