Saturday morning coffee [December 6 2014]

“The happiest people don’t have the best of everything, they just make the best of everything” ~unknown

Welcome to December. Hard to believe that Christmas is right around the corner.

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….

MUG_SMC
Continue reading Saturday morning coffee [December 6 2014]

Saturday morning coffee [August 9 2014]

“If you think a weakness can be turned into a strength, I hate to tell you this, but that’s another weakness.” -Jack Handey

So much happens each and every week that 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 coffee mug below is relatively new. It’s one of two that I picked up in Las Vegas at M&M World during one of my daughter’s volleyball tournaments earlier this year.

Orange M&M's Coffee Mug
Continue reading Saturday morning coffee [August 9 2014]

Medical errors remain a problem despite years of effort

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.1 Regardless of the actual reference, the bottom line is that the number of patients that die from preventable medical errors is high.
Continue reading Medical errors remain a problem despite years of effort

Saturday morning coffee [December 21 2013]

“Great people talk about ideas, average people talk about things, and small people talk about wine.” - Fran Lebowitz

So much happens each and every week that 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….

MUG_SMC

Continue reading Saturday morning coffee [December 21 2013]

Saturday morning coffee [March 30 2013]

MUG_MPSo much happens each and every week that 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 coffee mug to the right comes straight from Moonstone Pottery in Los Osos, California. It’s a pretty cool mug. It was a gift from my brother, Robert. Thanks bro.

The Croods was #1 at the box office last weekend to the tune of nearly $44 Million. I didn’t see that one coming. I knew that the movie was out, but had no interest in seeing it. My family chose instead to see Olympus Has Fallen. It was terribly predictable and a bit corny, but I liked it. It was full of lots of gratuitous violence and gun play, which makes it my kind of movie. Just for the record, Jack the Giant Slayer has officially flopped at the box office.
Continue reading Saturday morning coffee [March 30 2013]

CPOE reduces likelihood of error by nearly 50% [article]? I’m skeptical

There’s quite a bit of talk floating around the internet about a recent article in JAMIA that looks at reduction of medication errors in hospitals secondary to CPOE adoption (J Am Med Inform Assoc doi:10.1136/amiajnl-2012-001241). The article is available for free so I read through it last weekend. By the end I was looking at something that wasn’t all that impressive. The authors use a lot of sleight of hand, i.e. statistical models to tell a story about how CPOE “decreases the likelihood of error on that order by 48%”, which ultimately could potentially lead to a reduction in medication errors by approximately 12.5%”. That would be great, except that the entire thing is based on statistical models, assumptions, survey data and a great big meta-analysis.

ChiefStatistian
Continue reading CPOE reduces likelihood of error by nearly 50% [article]? I’m skeptical

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 good at things like this.

Accuracy of preparation of i.v. medication syringes for anesthesiology
Cyril Stucki, Anna-Maria Sautter, Adriana Wolff, Sandrine Fleury-Souverain and Pascal Bonnabry

Abstract

Purpose: The results of a study of the accuracy of i.v. medication preparation by anesthesiologists are presented.

Methods: The accuracy of syringe preparation was assessed by analyzing the contents of 500 unused syringes collected after adult and pediatric surgery procedures. The collected syringes contained various i.v. medication formulations representative of different preparation techniques: atracurium 1, 2.5, and 5 μg/mL and fentanyl 10, 20, 25, and 50 μg/mL, which required serial dilution after withdrawal of the drugs from ampuls; thiopental 5, 25, and 50 mg/mL, prepared by diluting reconstituted powdered drug from vials; and lidocaine 10-mg/mL solution, which was withdrawn directly from the ampul into a syringe. Variances between actual and labeled drug concentrations were determined via a validated ultraviolet–visible light spectro-photometry method.

Results: Overall, 29% of the evaluated syringes were found to contain drug concentrations outside the designated range of acceptability (±10% of the targeted concentration); 18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%. In one instance, the actual drug concentration was at variance with the labeled concentration by >100%. In 4% of cases ( n = 20), discrepancies exceeded 100%, suggesting not just imprecision but errors in the preparation process, such as incorrect dilution calculations and selection of the wrong medication vial by the syringe preparer.

Conclusion: Analysis of different i.v. formulations of four medications prepared in syringes by anesthesiologists revealed a high rate of discrepancies between ordered and actual drug concentrations, suggesting a need for increased institutional efforts to prevent errors during the preparation process.

Am J Health-Syst Pharm. 2013; 70:137–42

 

Saturday morning coffee [October 13 2012]

So much happens each and every week that 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 coffee mug to the right is from The Sixth Floor Museum at Dealey Plaza in Dallas, Tx. My family and I spent some time there during our summer vacation in Texas. One of the things I really wanted to do in Dallas was visit Dealey Plaza and the site where JFK was assassinated. Well, I finally got that chance as my family and I spent some time walking around the plaza area, visiting the location of the assassination and spending a little time at the book repository and museum. JFK is one of the few men in history that I would have liked to have met in person.

Taken 2 was #1 at the box office last weekend. My wife and I saw it last Saturday. Not bad. If you decide to go see it make sure you don’t want a good story line or incredible acting range. Just enjoy the senseless violence and be entertained. Hotel Transylvania was #2 at the box office. I saw that last night with my wife and youngest daughter. Good, clean humor. Worth seeing especially if you have little ones.

Continue reading Saturday morning coffee [October 13 2012]

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 we’re talking about; equation for healthcare technology “innovation” is ([today’s technology] -10 years).

The study found that requiring clinicians to re-enter patient IDs resulted in a 41% reduction in wrong-patient orders. Single-click confirmation of patient ID reduced wrong-patient orders by 16%. It’s not all peaches and cream though. The study found that double entry increased order entry by 6.6 seconds. Oh no!

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial (J Am Med Inform Assoc. 2012 Jun 29 )
Abstract
Objective: To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. Materials and methodsIn phase 1, from May to August 2010, the effectiveness of a ‘retract-and-reorder’ measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an ‘ID-verify alert’, and an ‘ID-reentry function’.
Results: The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71).
Discussion and conclusion: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

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 it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?
Continue reading Prenteral nutrition error [from #ISMP]