Building a Stronger Safety Net

If you have been in practice for even a short time, you may recall hearing about different types of medication errors that have occurred in your department or facility. In some cases, this same error—unbelievably—repeats itself, even after the organization spends significant time and resources investigating and “fixing” the issue at hand. Such repetitive events often leave practitioners, managers, and entire organizations discouraged and wondering what happened, where they went wrong, and what to do next. As illustrated in the following scenario, recalcitrant errors often deserve a reanalysis of the event to understand if an important component was overlooked but—more importantly—a critical assessment and revision of the preventive actions taken.