Medical devices enter the patient care arena frequently and entry points are numerous. While some are new, others have been upgraded or new software installed leading to an end product that reflects varied enhancements with complex technology. Unfamiliarity with devices can cause the end user to inadvertently cause injury or harm to a patient when user competence could make a life changing impact. Such was the case in a large health care system when unfamiliarity with a device led to death of a patient. This webinar will describe a “fail safe” process that has been put into place to support a high reliability journey to ensure competence of nursing and other health care professionals with new and enhanced medical devices. This process has resulted in a best practice and simple “stop” and a “fail safe” initiative as a part of a journey to save lives with “zero” harm as its goal.