Webinar – Lessons Learned from a Harmful Medication Error: Organization’s Role in Improving Safety

October 27, 2022
10:00am - 11:00am Pacific Time
CHI owner insured hospital and long term care risk managers, patient safety officers, quality improvement, direct care providers, pharmacy staff and leadership, clinical leadership, and clinical educators.


On March 25, 2022, most of the healthcare community was shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult following the 2017 death of Charlene Murphey. This case involved a combination of both active failures, including human errors and unsafe behavioral choices as well as latent failures within the organization. Regrettably, healthcare organizations tend to turn a blind eye to both risky systems and risky choices, believing patients are safe if bad outcomes—meaning harmful or fatal errors—do not happen to them. However, this type of error could happen anywhere given the current system vulnerabilities frequently found in hospitals.

This program will give an overview of the breakdowns in the medication-use process in this case as well as list examples of both active and latent failures. Discussion will include organizational response to human error, at-risk behaviors and to those who suffer emotionally when the care they provide leads to patient harm (often referred to as second victims). The speaker will present proactive ways to identify risk, including the use of error reporting programs and improving staff engagement to address unsafe practices before an error occurs. The program will conclude with a discussion of effective risk reduction strategies to prevent harm to patients.

Register Here

Learning Objectives

At the end of the webinar, the participant should be able to:

  1. Differentiate between human error, at-risk behavior, and reckless behavior
  2. Describe The Joint Commission Sentinel Event Alert #60 and how it relates to a Just Culture and care for second victims.
  3. List system design strategies that can prevent or detect human error or mitigate patient harm from errors.

Provider approved by the California Board of Registered Nursing, Provider number 12205 for 1 contact hour.


Matthew Grissinger RPh, FISMP, FASCP
Director, Education, Institute for Safe Medication Practices (ISMP)

Matthew Grissinger, RPh, FISMP, FASCP is the Director of Education at the Institute for Safe Medication Practices (ISMP). His responsibilities include working with healthcare practitioners and institutions to provide education about medication errors and their prevention and review medication errors that have been voluntarily submitted to ISMP’s medication errors reporting programs. He has published numerous articles in the pharmacy literature, including regular columns in P&T and is a journal reviewer for the Joint Commission Journal on Quality and Patient Safety, Pharmacoepidemiology, BMJ Open Quality, Drug Safety, and Annals of Internal Medicine. He is a chapter contributor to many textbooks including Pharmacy Management: Essentials for All Practice Settings, Essentials of Nurse Informatics, Remington and Medication Errors. He is recently completed the Just Culture certification course.

Mr. Grissinger serves as the Chair for the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) and is Co-Chair of the National Quality Form (NQF) Common Formats Expert Panel. He also served on the WHO Focus Group on Measurement Tools for Medication Safety, USP Safe Medication Use Expert Committee from 2005-2010, the FDA Proprietary Name Review Concept Paper workshop panel in 2008, FDA Naming, Labeling, and Packaging Practices to Minimize Medication Errors workshop panel in 2010 and the Joint Commission Home Care Compounding Pharmacy Technical Advisory Panel in 2013. He is also an adjunct assistant professor for Temple University School of Pharmacy.


Web Access

Zoom connection information is auto-generated and emailed to the participant upon registration.  Each participant has a unique link for connection.


Zoom connection information is auto-generated and emailed to the participant upon registration.  Each participant has a unique link for connection.