AMEE Special Interest Group on Patient Safety: Medication Safety of High Alert Medication

We discuss an incident of hyperkalemia management that resulted in an insulin overdose.

This is an interview of the interprofessional team who worked on the root cause analysis and risk reduction strategies.

The team discusses human factors, system and education changes that resulted from this incident in an effort to prevent this from happening again, minimize the harm level and discuss how to sustain the improvements.