IV Mistake Prevention

[owlegrad]

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We had an IV given to the wrong patient today, a mistake I have seen several times. What do y'all do to prevent this? Or is it just a fact of life?

 

[PumpkinSmasher]

We had an IV given to the wrong patient today, a mistake I have seen several times. What do y'all do to prevent this? Or is it just a fact of life?

Barcoding

 

[Carboxide]

That's the nurse's job. They're responsible. Unfortunately they're not great at double checking names.

 

[PumpkinSmasher]

That's the nurse's job. They're responsible. Unfortunately they're not great at double checking names.

Actually it is a hospital problem. If a patient is injured, it isn't the nursing department who will get sued it will be the hospital. I believe the pharmacy department is part of the hospital...you think? Pharmacy is responsible for the medication delivery process in a hospital, we can not control every aspect or be blamed for every error by any means. But what we can do, is identify safety measures and advocate for technology that will improve patient safety and the overall efficiency of the med. delivery process.

Just saying "It is nursing's problem", does not help anyone,shows lack of leadership abilities and lack of problem solving skills.

 

[Carboxide]

Actually it is a hospital problem. If a patient is injured, it isn't the nursing department who will get sued it will be the hospital. I believe the pharmacy department is part of the hospital...you think? Pharmacy is responsible for the medication delivery process in a hospital, we can not control every aspect or be blamed for every error by any means. But what we can do, is identify safety measures and advocate for technology that will improve patient safety and the overall efficiency of the med. delivery process.

Just saying "It is nursing's problem", does not help anyone,shows lack of leadership abilities and lack of problem solving skills.

I mean, yeah, barcoding would be awesome, but unless we bring ALL bags directly to the patients' rooms (which is not going to happen, especially when you consider how many are refrigerated) we can't really do much about it. What's your solution? And you better not say barcoding, because that's already been mentioned (twice now) and also because it doesn't really have anything to do with pharmacists helping with that. What can YOU PERSONALLY DO?

 

[PumpkinSmasher]

I mean, yeah, barcoding would be awesome, but unless we bring ALL bags directly to the patients' rooms (which is not going to happen, especially when you consider how many are refrigerated) we can't really do much about it. What's your solution? And you better not say barcoding, because that's already been mentioned (twice now) and also because it doesn't really have anything to do with pharmacists helping with that. What can YOU PERSONALLY DO?

Either you are dense or just did not read carefully but you missed the point entirely. Good luck in the real world, you will need it.🙄

 

[QofQuimica]

We're *all* responsible, and by all, I mean every single person on the health care team, from the attending physician to the third year medical student, as well as the pharmacist, the nurse, family members, even patients themselves if they're alert enough to know what's going on. Medicine is a team sport. Anyone who sees something wrong is obligated to speak up.

Owle, to answer your question, the nurses here do a two-step verification before administering medications that involves asking patients to state their name and DOB. If the patient is unable to do this, the nurse physically checks their identification bracelet. Some departments do use bar codes as well.

 

[PharmDstudent]

We're *all* responsible, and by all, I mean every single person on the health care team, from the attending physician to the third year medical student, as well as the pharmacist, the nurse, family members, even patients themselves if they're alert enough to know what's going on. Medicine is a team sport. Anyone who sees something wrong is obligated to speak up.

This is complete bull****. Being dedicated to your profession and being responsible are not one in the same.




Team conferences, P&T, and walk-through meetings help somewhat, because everyone knows what conditions the patient has (and does not have) --> reducing the chance of giving a med that the patient isn't supposed to be on.

Whenever I check prescriptions, I try to make sure that they all "fit". For example, a patient should not be getting a bolus of potassium and kayexalate simultaneously or pyridium and hydrocodone without an antibiotic to treat the bladder infection.

 

[QofQuimica]

This is complete bull****. Being dedicated to your profession and being responsible are not one in the same.

I don't think that you and I mean the same thing when we're using the word "responsible." I am not using the word in the sense of liability; I'm responding to the assertion above that it's the nurse's job and not anyone else's to make sure there are no mistakes with medication administration. That's not true. Or more exactly, it shouldn't be true. Because nurses aren't any more perfect than the rest of us. So if the pharmacist notices the nurse making a mistake, of course s/he should speak up.

It's not impossible that a pharmacist could catch a nurse's mistake, incidentally. In the ICUs at my hospital, the critical care pharmacists physically come on rounds with us and go over each patient's meds, make recommendations, etc. The pharmacy also has the records of all meds ordered and administered on the floors, so again, they might catch the mistake if a nurse tried to administer a med in a patient's name but no order was written for it by the doctor.

 

[PharmDstudent]

I don't think that you and I mean the same thing when we're using the word "responsible." I am not using the word in the sense of liability; I'm responding to the assertion above that it's the nurse's job and not anyone else's to make sure there are no mistakes with medication administration. That's not true. Or more exactly, it shouldn't be true. Because nurses aren't any more perfect than the rest of us. So if the pharmacist notices the nurse making a mistake, of course s/he should speak up.

It's not impossible that a pharmacist could catch a nurse's mistake, incidentally. In the ICUs at my hospital, the critical care pharmacists physically come on rounds with us and go over each patient's meds, make recommendations, etc. The pharmacy also has the records of all meds ordered and administered on the floors, so again, they might catch the mistake if a nurse tried to administer a med in a patient's name but no order was written for it by the doctor.

Come on now... as if someone is going to watch (or oversee) someone else give the wrong medication...

 

[rxlea]

We also use two step verification. We also post name alerts in the med rooms and on the Pyxis machines for patients with the same or similar first/last names. I agree that we all have a part in patient safety. Everyone makes mistakes, which is why things are checked so many times during the process. Of course accountability is important but there should be a team effort rather than pointing the finger. Training and education should always be a part of the solution.

 

[Twiggy1]

And you better not say barcoding, because that's already been mentioned (twice now) and also because it doesn't really have anything to do with pharmacists helping with that.

What about barcoding? 😀😛🙄