Change Management in Response to Preventable Tragedies
This bulletin outlines the changes made to an institution, and how they were implemented, following the occurrence of 2 never-events involving concentrated electrolytes being administered to pediatric patients. Steps taken include the following: recognizing the need for change, building a multidisciplinary team to guide change, developing strategies to reinforce change, communicating strategies to promote buy-in, anchoring the change in organizational policies and procedures, and incorporating continuous monitoring and assessment.
- Preprinted label
- Computerized order sets
- Mistaken Identity – A Recurring Problem