Medication Safety

Accuracy of preparation of i.v. medication syringes for anesthesiology [article]

Here’s an interesting article from the January issue of AJHP that talks about the accuracy of medication syringes used in surgical procedures. Some of the findings are a bit unnerving: “18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%“. Humans, we’re just not all that […]

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Excessive acetaminophen dosing in hospitals more common than you might think

Archives of Internal Medicine: “A total of 14 411 patients (60.7%) were exposed to acetaminophen, of whom 955 (6.6%) exceeded the 4 g per day maximum recommended dose. In addition, 22.3% of patients who were 65 years or older and 17.6% of patients with chronic liver diseases exceeded the recommended limit of 3 g per […]

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Combination lock to prevent blood transfusion errors? Why not

medGadget: “Typenex Medical, a Chicago, Illinois company, has created a solution that pretty much eliminates the possibility for errors. The system utilizes a combination lock on the blood bag that will only open using a code printed on the patient’s armband. If a clinician accidentally attempts to open the bag using another patient’s code, it […]

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More on the meningitis outbreak caused by contaminated steroid injection

Things just keep getting worse: death toll rose to 14 and people affected was up to 172 in 11 states as of this afternoon. It’s difficult to find accurate information on the exact cause of the meningitis, but it appears that most of the cases are related to either Aspergillus or Exserohilum. Fungal infections are […]

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Outsourcing sterile product preparation and the importance of quality assurance

I’m sure you’ve heard about the recent meningitis outbreak tied to a contaminated batch of preservative-free methylprednisolone acetate. The story has received significant attention as more that 100 people have been sickened and as many as eight have died as a result of receiving an injection of the contaminated steroid (this data is already out of date […]

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A trip to IHOP and more thoughts on color

A trip to the local IHOP (@IHOP) this morning for breakfast with my family reminded me of something I saw a couple a weeks ago and this post about the use of color in pharmacy labels. It’s a big of a stretch, I know, but the things that pop into one’s mind aren’t necessarily controlled by logic.

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Forcing re-entry of patient ID cuts wrong-patient errors

You know how websites make you double enter your email address and password when you sign up for a service? Well, apparently that’s not a bad system for making sure you have the right patient during order entry. You’d think we would have figured that out a while back, but then again this is healthcare […]

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Prenteral nutrition error [from #ISMP]

From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics. The big difference between these two is how you order electrolytes; it’s a really big difference. The most shocking part of all this was that the error made […]

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Warning labels on outpatient prescription vials not so great after all

Everyone has seen them, I know you have. Those little colored labels that the pharmacy slaps on your bottle when you get a prescription: “May cause drowsiness”, “Avoid excess sun”, “Do not take aspirin products without doctor approval” and so on. There are a ton of them. I remember seeing them lined up in front […]

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Article: The costs of adverse drug events in community hospitals

The article below appeared in the March 2012 edition of Joint Commission Journal on Quality and Patient Safety – yes, that’s a real journal. I couldn’t make this stuff up – Anyway, there’s nothing new here, we all know that ADEs are expensive. How expensive? Well, the bottom line is that “ADEs were associated with an increased adjusted […]

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