I’ve been slowly reading ‘Thinking, Fast and Slow’, a best-selling book by Daniel Kahneman, a Nobel Prize winning psychologist and economist known for his work on the psychology of judgment and decision-making. The book summarizes behavioral science research conducted by Kahneman. The recurring theme of the book is what the author defines as two modes … Read more
While not directly related to pharmacy, the SurgiCount Safety-Sponge System is kinda’ cool. The system uses low-tech barcode technology to prevent surgical sponges from being left behind in patients. Simple yet effective. “The system uses sterile bar-coded sponges and a computer tablet loaded with proprietary software to ensure that all sponges are tracked. After approximately 11 … Read more
First of all, is it tall man, tall-man, or tallman? And why is it called “tall man lettering” when none of the letters are actually taller than the others? Heck if I know. Just more questions in a mountain of questions piling up around tallMAN lettering. Pharmacy Practice News: “[The study] found that there hasn’t been a substantial … Read more
I quite literally stumbled across this the other day while doing research for another project. I heard that ISMP had updated their best practices document, but didn’t see an official announcement. It’s possible I just missed it. The document contains some great new safety recommendations. All in all there are eleven best practices listed. Most … Read more
A friend and colleague, Ray Vrabel, left a comment on my post from April 20th. I thought what Ray had to say was too good not to post. He raises some good points, which are worth more discussion. Ray is a sharp guy, and he and I have had some good conversations over the past … Read more
Last week I wrote about the tragic death of a patient caused by a drug error (CSP error results in death of a patient). One day later on December 18, 2014, ISMPÂ also addressed the error in the Acute Care edition of their biweekly ISMP Medication Safety Alert, i.e. one of their newsletter. I had hoped … Read more
A 65-year-old woman died at St. Charles Medical Center in Oregon after being given an infusion of rocuronium instead of fosphenytoin. “The prescription was entered correctly into the electronic medical records system, and the pharmacy received the correct medication order, the AP reported. The IV bag was also labeled properly. After the pharmacy worker mistakenly … Read more
I recently read an article at Senator Bernie Sanders website about preventable medication errors. The article lists preventable medical errors in hospitals as the third leading cause of death in the U.S. behind only heart disease and cancer.
The article goes on to say that “the Journal of Patient Safety recently published a study which concluded that as many as 440,000 people die each year from preventable medical errors in hospitals. Tens of thousands also die from preventable mistakes outside hospitals, such as deaths from missed diagnoses or because of injuries from medications.” I’m not exactly sure what article they’re referencing here as they didn’t provide a link or additional information, but I assume they’re referring to the article by James in September 2013. Just a guess, I could be wrong.1Â Regardless of the actual reference, the bottom line is that the number of patients that die from preventable medical errors is high.
There’s an interesting article in the April 2014 edition of Drug Safety that looks at English Twitter posts from November 2012 through May 2013 to see if there is any correlation between adverse event (AEs) reporting via Twitter and more “official†channels. The authors collected public Tweets, which were subsequently stored for analysis using Amazon … Read more
