“An error doesn’t become a mistake until you refuse to correct it.” – Orlando A. Battista
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 morning along with some random thoughts….
The mug below was sitting next to my laptop filled with chocolate covered espresso beans last Saturday morning, Valentine’s Day. A gift from my lovely wife. Apparently she’s aware of my addiction. It made me smile.
“Fast is good, accurate is better.†– unknown
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 morning along with some random thoughts….
I briefly mentioned the Intelliport Medication System from BD in a previous post. The technology and potential use cases are impressive. The BD Intelliport System offers: Drug and concentration information is presented to the user via audio and visual feedback. The system pulls information from the bar code on the syringe as it’s inserted into … Read more
The tragic death of a hospitalized patient in Oregon [1] has once again put a spotlight on pharmacy i.v. rooms. Unfortunately this isn’t the first i.v. error to harm, or kill a patient and I’m sad to say that it probably won’t be the last. We know that IVs present higher risks than most other medications and the literature presents abundant evidence of the prevalence of pharmacy compounding errors which result in patient harm or death.2-11
According to a 1997 article by Flynn, Pearson, and Baker: A five-hospital observational study on the accuracy of preparing small and large volume injectables, chemotherapy solutions, and parenteral nutrition showed a mean error rate of 9%, meaning almost 1 in 10 products was prepared incorrectly prior to dispensing.6
The inherent problem with compounded sterile products (CSPs) is that the efficacy of IV medication administration hinges on the integrity of dose preparation and labeling in the pharmacy. If an item is compounded incorrectly in the pharmacy, no amount of verification at the bedside will alter that. Other than looking at an IV bag or syringe to ensure that no gross particulate matter is present, without chemical analysis it is impossible to verify the contents. Occasionally a color change will acknowledge the addition of the correct additive – yellow multivitamins, red doxorubicin, and so on – but even then, the correct amount (volume/dosage) cannot be verified.
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
“A doctor who works without error is not a genius. He is a liar.†~unknown
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 morning along with some random thoughts….
For the better part of the past year I’ve been working on a project with Mark Neuenschwander of The Neuenschwander Company looking at technologies used in pharmacy clean rooms to prepare sterile compounds.
The research into this area took much longer than originally anticipated. We discovered along the way that this subject is much more complex than it appears on the surface. Information is difficult to find, some of the technologies are little more than marketing material on a company website, and the subject matter is in its infancy.
Yesterday I went through the drive-thru of a local fast food chain. The young lady manning the register asked for my order, so I started giving it to her. She asked me to pause for a second, and when she resumed she repeated the first part of my order back to me. She had it … Read more