Kaiser Permanente Risk and Safety Assessment – Vanderbilt Case Review and Learning

September 5, 2024 | 10:00 - 11:30AM PT

Medical errors continue to be significant across the country with medication errors being the most common medical error. The Vanderbilt Medical Center Wrong Medication Error by Nurse Redonda Voight hit the news and has been dramatically impacting nursing and their desire to stay in healthcare for fear that they may be criminalized for making an unintended mistake. Understanding the risk is prevalent in healthcare, Kaiser Permanente (KP) National Safety Committee (NSC) took a proactive approach to analyze this case to understand the learnings and potential risks of something similar happening here at Kaiser Permanente. How could we take the learnings to further mitigate any risk of such occurrence within our own organization?

The team spent a lot of time learning about the facts of this case and the opportunities/ risks involved. As part of this process, the team performed a detailed analysis and walked the case through cause mapping and through our Kaiser Permanente just culture algorithm to see how we would have responded. In the detailed analysis of this case, several systems design failures as well as individual human factors were found. From these learnings, a detailed action plan was created to reduce the risk from occurring at Kaiser Permanente. This case review and learnings are shared in this webinar.

Presentation topics include:

  • Discuss the general facts surrounding the events of the Vanderbilt Wrong Medication Error resulting in patient death.
  • Recall and explain how to complete a cause map for sentinel event analysis.
  • Describe contributing factors to the Vanderbilt Wrong Medication Error Event and list the factors that support systems design and human factors engineering in performance improvement.
  • Recognize the difference between low, moderate, and high leverage effectiveness strategies in action planning, as they are related to the KP Hierarchy of Effectiveness.
  • Identify principles of high reliability that can be incorporated into performance improvement and action planning following event analysis.
  • Express how to analyze individual accountability in a just way, utilizing the Just Culture Algorithm.

Register via GoToWebinar.

Thursday, Sept. 5, 2024: 10:00 a.m.- 11:30 a.m. (PT)

Tametha I. Stroh, MSN, RN, CPPS, CPHRM
Nurse Director Risk Management and Patient Safety

Tametha joined Kaiser Permanente in May 2019 and serves as the Nurse Director for Risk Management and Patient Safety. Tametha holds a Master of Science in Nursing (Nursing Leadership Concentration) and a Bachelor of Science in Nursing from San Diego State University. She is an experienced nurse executive with over 15 years specializing in quality, patient safety, accreditation, and regulatory licensing as well as clinical and administrative leadership. She holds triple certifications in Patient Safety, Risk, and Lean Six Sigma which allow her to bring advanced skills to the table and combine both quality and performance improvement methodologies to lead risk reduction strategies across the enterprise.

Jennifer Matias, PharmD, BCPS, CPPS
Director, Pharmacy Quality and Medication Safety

After completing residency training, Jennifer worked as a pharmacist for 10 years in a variety of hospital settings including community-based hospitals, a pediatric hospital, and the Veterans Affairs Health System.
She later pursued a formal medication safety role at the Riverside University Health System Medical Center before coming to Kaiser Permanente in 2019 where she now supports and leads medication safety initiatives across the organization.

Elaine J. Huggins, RN, MSN, CPHQ, L/SS Master Black Belt
HSP Lead Principal Consultant, High Reliability

Elaine supports Kaiser Permanente’s High Reliability journey at the Program Office in Oakland, CA. She brings 20 years’ experience as an Army nurse with a master’s degree in nursing administration/education and clinical experience in medical/surgical/oncology/orthopedic/emergency/PACU and psychiatric nursing in both frontline and supervisory positions. She also brings another 10 years in the Department of Defense civilian corps as a Certified Professional in Healthcare Quality (CPHQ) supporting the DoD healthcare quality mission, which included accreditation, patient safety, risk management and performance improvement. During that time, she
obtained her Black Belt from the University of Tennessee, supported by the U.S. Air Force, and returned to work in their Space/Missile launch program providing improvement services at Vandenberg Air Force Base, CA.

Elizabeth Rebo, PharmD, MBA, CPPS
Executive Director, Pharmacy Quality and Medication Safety

Elizabeth graduated in 2000 from Clemson University with a Bachelor of Science in Biological Sciences. She then attended the University of South Carolina and received her Doctor of Pharmacy in 2004. Upon graduation, Elizabeth worked as a critical care pharmacist at Wake Forest University Baptist Health. In 2006, Elizabeth moved to Novant Health Forsyth Medical Center and served as the investigational drug studies/medication safety clinical pharmacist, until 2009, at which time she became the medication safety coordinator for the Novant Health Winston Salem market. In 2010 Elizabeth moved into a system role as the medication safety manager, with responsibilities over 13 acute care facilities.  In 2013 Elizabeth moved to Atlanta, GA and worked until 2019 at WellStar Health System, last serving as the executive director of medication safety. In December 2019 Elizabeth moved to Los Angeles, CA and is currently serving as the executive director of pharmacy quality and medication safety for Kaiser Permanente’s national pharmacy services. Elizabeth’s role includes executive oversight of the pharmacy IA (Intelligent Automation) portfolio.

HQI is an approved continuing education (CE) provider by the California Board of Registered Nursing and will provide CHPSO members an opportunity to earn CEs. Provider Number CEP16793 for 1.0 contact hour.

Please contact CHPSO at info@chpso.org if you have any questions.