Patient Safety

Today’s sterile compounding climate is a lesson on availability cascades

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 […]

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ASHP Midyear 2018: Initial Thoughts

I recently returned from the 2018 ASHP Midyear Clinical Meeting, i.e. “Midyear” in Anaheim, CA. This year was a bit different for me as it was the first time in many years that I attended the meeting as a regular pharmacist, i.e. not tied to a pharmacy automation company as an employee or as a […]

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It’s time to disrupt pharmacist order verification

Several years ago there was a debate over the long-time practice of having pharmacists review all medication orders prior to administration; referred to as nearly universal prospective order review (NUPOR).(1) At the heart of the debate was whether or not such a process was still relevant in the changing face of healthcare, i.e. do pharmacist […]

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Saturday morning coffee [September 16 2017]

“Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?” — Matthew 7:3 (NIV) So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this […]

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IV workflow management systems and workarounds

A large portion of the most recent issue of the ISMP Medication Safety Alert is dedicated to IV workflow management systems (IVWFM) and errors caused by workarounds. There are a few head-scratchers in the list to be sure. There are even some that had me speculating their authenticity, i.e. too wacky to believe. “Data submitted […]

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A “no-mistakes sponge system” — bar-coded sponges in the OR

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 […]

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Compounding Today: state board of pharmacy concerns with USP <800>

Each Friday the CompoundingToday Newsletter faithfully appears in my inbox. The newsletter features commentary by Lloyd V. Allen, Jr., Ph.D., RPh, Editor-in-Chief of the International Journal of Pharmaceutical Compounding. Dr. Allen is a legend in the pharmacy compounding world for both sterile and non-sterile products. He was someone that I looked up to during my […]

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Automated detection of LASA medication errors

  Look-alike/sound-alike (LASA) medications – also referred to as sound-alike, look-alike drugs (SALAD) (1) — have been a thorn in the side of healthcare professionals for as long as I’ve been a pharmacist. Many solutions to the LASA problem have been proposed, including Tall Man Lettering (2), physical separation of look-alike drugs, printing of both […]

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Thoughts on my time with DoseEdge Pharmacy Workflow Manager 

Yesterday, I had a great opportunity to spend the day using DoseEdge in its native environment. That is to say, I staffed at a facility that was using DoseEdge in its cleanroom to prepare CSPs, including patient-specific products as well as stock bags, TPNs, etc. I’ve used DoseEdge for brief periods in the past. I’ve […]

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ISMP releases new medication safety best practices document

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 […]

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