Learning and Process Improvement after a Sentinel Event

Abstract

At a Denver area hospital in October 1996, a medication error resulted in the death of an infant. With assistance from the Institute for Safe Medication Practices, the departments involved performed a root-cause analysis to determine the specific safety failures that led to the error. The pharmacy department determined its role in the error, then developed a mathematics competency requirement, a medication order double-check system, and clinical pharmacy services that addressed the identified system failures.