A Mountain of Mistakes: Moving from Unspoken Tragedy to Effective Collaboration

Course overview

It is said that success sits atop a mountain of mistakes. Healthcare teams boast unprecedented resources and tools for reduction in medication error. Despite staggering technological advances, errors continue. In fact, new opportunities for error have emerged with some of the very tools intended to eliminate systematic errors. Using established psychological principles, human engineering factors are examined and extrapolated to the unique challenges of the contemporary pharmacy setting. Recurring problematic areas in pharmacy practice will be extensively examined within the framework of an effective Continuous Quality Improvement (CQI) Plan and appropriate use of the Root Cause Analysis (RCA) method in identifying, reporting, and evaluating sentinel events. The vitality of intra- and inter-professional communications is emphasized throughout the didactic structure of this presentation.