ABSTRACT
This chapter seeks to raise awareness of a vision for a future in which EI&K plays a strategic role in patient safety improvement. It is submitted that even rare occurrences such as vincristine misadministration should provide opportunities to motivate and encourage innovation in EI&K practice for individual practitioners, hospital leadership and the patient safety community to more reliably share knowledge to reduce errors. The chapter uses the context of vincristine administration error to explore how the ineffective use of EI&K could be construed as system failure contributing to patient harm. It illustrates the value of effective organizational application of EI&K to learn from error experience in order that the healthcare community at large may generate improvement through motivation, investigation and innovation. The chapter also explores Kaiser Permanente Northern California case. Kaiser Permanente Northern California (KPNC) goals were supported through attention to EI&K transfer.
