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Resource in Medication updated 4 Mar 2015

In this webinar held on 27 February 2015, Gillian Bohm (Health Quality & Safety Commission’s Principal Advisor, Quality Improvement) was joined by panel members Sandy Blake (Director of Nursing, patient safety and quality, Whanganui DHB and Clinical Lead, Reducing Harm from Falls programme), Karen O’Keefe (Clinical Lead, First, Do No Harm) and Beth Loe (Commission’s Medication Safety Specialist).

They presented on:

  • root cause analysis
  • human factors and how understanding these can help prevent errors and harm
  • error prevention strategies and the most effective methods for system change to prevent errors and harm.

Using medication-related adverse event case studies, the panel reflected on how considering human factors and system changes could prevent the same event happening again.

Listen to the recording by clicking the link below.