Medication Errors

Small labeling changes to phenytoin unit dose cup causes confusion

August 12, 2010 issue of the ISMO Medication Safety Alert the issue of : “We have received a number of reports about the labeling of Xactdose unit dose liquid containers from VistaPharm, Inc., of Birmingham, AL. The company recently changed the way the drug concentrations are expressed on their labels. An example is phenytoin oral […]

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Is the 30-minute rule for medication administration good or bad?

The June 17, 2010 issue of ISMP Medication Safety Alert I received has an interesting article on the unintended negative consequences of the Centers for Medicare & Medicaid Services (CMS) regulation requiring medications to be administered within 30 minutes of their scheduled dosing time. I’m sure that the CMS 30-minute rule was created with good […]

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An almost disastrous bar-coding mishap

At some point in the past few days it was decided that our technicians should re-label all injectable controlled substances with one of our “after market” flag labels. I’m not sure when or how the decision was made, but it was. When questioned about it, the rationale behind the decision was that the nurses were […]

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A look at one pharmacists unwanted potential

A recent post by John Poikonen got me thinking about medication errors. They’re part of every pharmacists day, but we rarely give them much thought. I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, […]

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We need a better system for medication reconciliation

Medication reconciliation is defined by JCAHO as “the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.” The process should be fairly straight forward, but it is actually very […]

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Sad, but all too common experiences with healthcare

I read Warner Crocker’s musings at GottaBeMobile as well as his Tweets via the @LPH/tablet-pc-enthusiasts list on Twitter. Warner also has a second blog called Life On the Wicked Stage: Act 2, which I do not read with any regularity. I was, however, driven toward his personal blog secondary to a Twitter post. The post, […]

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Who should collect allergy information and how should it be done?

A pharmacists review of a patient medication regimen is never complete without a thorough evaluation of the patients allergy history. Unfortunately our hospital information system suffers from the inability to prevent people from being human and making mistakes. Our clinical information system permits ‘free texting’ of allergy information, resulting in misspelled drug names and therefore […]

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For those that need a reason to support CPOE and EMR implementation

Pharmacists see hand written orders like the one below almost daily. The order has to be interpreted by a pharmacist, usually with a little hand waving and guessing (kind of like being a pharmacy Jedi), and entered on the patient’s medication profile before the nurse can access the medication from the automated dispensing cabinet and […]

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A couple of articles on medication errors worth reading

The entire June issue of the British Journal of Clinical Pharmacology (BJCP)  is dedicated to medication errors. It’s worth your time to browse all the articles, but the two below were of particular interest to me. Agrawal A. Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology. 2009 ;67(6):681-686. The article covers […]

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