As part of their efforts to implement medication reconciliation, Stanford Hospital and Clinics developed Patient Safety Net (PSN), an online adverse event reporting system. Analysis of PSN data revealed a pattern of unrecognized, widespread, low-frequency I.V.-PCA adverse events. A performance improvement-failure modes and effects analysis identified causes, and a multidisciplinary team developed solutions. This article is part of a series that describes the Institute for Healthcare Improvement's 100,000 Lives Campaign recommended interventions from a nursing management perspective.

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