Development of a Common Cause Analysis Program and Its Evolution
Enhancing a Culture of Safety Through Collaborative Case Review
Fall Prevention Through Focused Communication
Anticipation of Error for High Reliability: The Failure Mode Effects Analysis
Implementation of Accountability and Performance Improvement Structures
Investigating the Impact of Integration of Pharmacists in Psychiatry Primary Care Teams
Mitigating Risk of Oxygen Related Patient Safety Events in the Emergency Department
Patient Safety Champions in the Ambulatory Setting: Our Journey to High Reliability
September 12, 2022
We have made progress on a culture of safety, but that may have been undone by the incident involving the former Vanderbilt University Medical Center nurse criminally prosecuted and found criminally liable for a fatal drug error in 2017. While individual accountability is important, more so are the systems that should be put in place to make safety achievable and sustainable. During this session, a panel of experts will discuss the case, and the impact it has had on culture of safety. The session will focus on how individuals working in healthcare quality and safety play a role in ensuring the right structures, process, and systems and leadership are in place to avoid these situations in the first place. You will leave this session with takeaways to contribute to the design and delivery of a safe care system.  
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