Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error


Are you troubled by the criminalization of a medical error that recently occurred within a present-day healthcare organization? How do we come to the right conclusions about accountability? Are you looking for ways to prevent similar events from occurring in your own organization?

Join leaders from ISMP and The Just Culture Company for a 90-minute conversation about lessons learned in the aftermath of a fatal medication error. You'll learn more about common, yet often unresolved system vulnerabilities, as well as key strategies and priorities needed to advance your organization's safety journey.

Intended Audience:

  • Healthcare Providers of all Disciplines

  • Healthcare Managers, Directors, and Executives

  • Medication Safety Leaders, Patient Safety and Quality Leaders

  • Professional Healthcare Provider Faculty


Judy Smetzer, BSN, RN, Publication Consultant, ISMP


Michael Cohen, RPh, MS, ScD (hon.), DPS (hon.), President Emeritus, ISMP

David Marx, BS JD, Chief Executive Officer, Outcome Engenuity, LLC, Parent of the Just Culture Company, LLC & Trajectories LLC

Barbara Olson, MS, RN, CPPS, FISMP, Senior Advisor, The Just Culture Company



Just Culture
This webinar is being presented in cooperation with The Just Culture Company.

CE Accreditation

No continuing education credits are available for this activity. 


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