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Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness.
Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. Patient Safety. 2024;6(1):117504. doi:10.33940/001c.117504.
System-based strategies are considered the most effective in reducing adverse events. This study evaluates the proposed action plan of an academic medical center following a fatal medication administration event against the Institute of Safe Medication Practices’ (ISMP) hierarchy of effectiveness. Only two of the 25 strategies were considered highly effective, high leverage system-based strategies. The authors also recommend fostering a “just culture” that advocates for system accountability.
