From Drug Shortage to Order Entry Error to Device Failure: Managing a TPN Event in a Large Health System

Wednesday, December 5, 2012
8:00 AM – 9:45 AM

Activity #: 204-000-12-284-L05P / 204-000-12-284-L05T
Level of Content: General Interest
2.00 Contact Hours / Application-based
Program Chair: Bonnie Levin, PharmD, MBA

Learning Objectives:

• Identify common pharmacy human factors failure points which could lead to extensive system errors.
• Analyze process improvements which can be used to effectively prevent the identified potential failures.
• Describe the safety processes which should be required to replace drugs that cannot be obtained due to shortage.
• Describe leadership strategies and tactics to effectively handle a serious medication error or other patient safety event.
• Evaluate the use of the "Just Culture" concept and its implementation during a serious medication error.