Risk Management

[militarymd]

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Gaba was the speaker....and he's a fool.


He compared anesthesia safety issues to aviation safety issues. Such comparisons are only valid when certain underlying assumptions/rules are the same.

In aviation simulators...if you fail, you don't go on your merry way and keep doing whatever you were doing before....like anesthesia simulators...you kill the dummy, the next day you're back doing anesthesia.

Do you know how many F-14 hopefuls wash out??? I don' know the exact numbers, but I'll tell you it is orders of magnitude higher than the number of medical students and residents who washout.....

So for the Simulator to be effective in improving safety, people who fail need to stop doing anesthesia....that is not the case. Gaba himself said there is no data to support that "systems" improve safety.....but if it works for the aviation industry.....Yea...that's a good comparison.

"Systems" may help decrease errors. "Systems" may make it easier to avoid errors, but the ULTIMATE source of the error IS the individual.

If one CANNOT handle working more than 24 hours at a time, then that INDIVIDUAL needs to stop working at the 24 hour mark.

If you screw....YOU screw up....not the surgeon, not the hospital, not the "system"

still true today

 

[MDEntropy]

OK.
So, hypothetically, if you were placed in a lousy system do you believe your performance would be equivalent to what it would be if you were placed in a very good system?

 

[militarymd]

Why does an individual make a mistake? Simple, they either didn't know any better or they weren't paying attention, or they made an error in judgement....errors in judgement is where experience comes from...hence I'm asking yours....seems you have little...otherwise you would tell us. I have a colleague who ordered gentamicin for a total knee yesterday because the patient had an prosthetic aortic valve. He made an error....why??? because he never read the 1997 AHA guidelines because he is lazy and doesn't read.



The data supports having trained "individuals" taking care of these patients.

I was in the Navy for 11 years, I know plenty of real pilots...and FIGHTER pilots at that. If they fail the simulator, they don't fly....doctors can fail simulators, they still practice...hell there are plenty who don't even pass their boards and they practice.



I spoke with the man. I assessed his OPINIONs. I asked a few questions. My assessment is he is a fool and now I'm telling my internet friends.

He paid me about a thousand dollars to go listen to him, so who's the fool.

as I had suspected...you were and are still, someone with little to no experience.

 

[militarymd]

OK.
So, hypothetically, if you were placed in a lousy system do you believe your performance would be equivalent to what it would be if you were placed in a very good system?

Depends on HOW you define "performance".....

if defined in terms of "quality" of care...YES...it would be exactly the same...

if defined in terms of "quantity" or "efficiency" of care...it would be decreased.

 

[MDEntropy]

Depends on HOW you define "performance".....

if defined in terms of "quality" of care...YES...it would be exactly the same...

if defined in terms of "quantity" or "efficiency" of care...it would be decreased.

Yes, I finished my residency several years ago. I have less OR experience than you, And I will never catch up to you until you quit. Let's get that out of the way.

Now, I wouldn't equate quantity and efficiency. The latter, at the very least, implies some sort of ratio that utilizes both quantity and quality.

So, I guess what's important here is how you define performance. That is, are you interested in maximizing only quality, only quantity or some combination of both (i.e. efficiency)?

 

[militarymd]

Yes, I finished my residency several years ago. I have less OR experience than you, And I will never catch up to you until you quit. Let's get that out of the way.

Now, I wouldn't equate quantity and efficiency. The latter, at the very least, implies some sort of ratio that utilizes both quantity and quality.

So, I guess what's important here is how you define performance. That is, are you interested in maximizing only quality, only quantity or some combination of both (i.e. efficiency)?

hey slick...

I really like how you are changing the premise.....this started with SAFETY.

Not any of the other crap that you are now addressing.

 

[MDEntropy]

hey slick...

I really like how you are changing the premise.....this started with SAFETY.

Not any of the other crap that you are now addressing.

Nothing slick here, safety is a key component of quality and I thought we were on the same page there.

Let me change my question slightly so you will not think I am trying to be slick.

So, hypothetically, and in both cases assuming an equivalent amount of work is done in an equivalent amount of time, if you were placed in a system which is lousy from a safety perspective do you believe the safety of your individual practice as a physician would be equivalent to what it would be if you were placed in a very good system from a safety perspective?

 

[militarymd]

Nothing slick here, safety is a key component of quality and I thought we were on the same page there.

Let me change my question slightly so you will not think I am trying to be slick.

So, hypothetically, and in both cases assuming an equivalent amount of work is done in an equivalent amount of time, if you were placed in a system which is lousy from a safety perspective do you believe the safety of your individual practice as a physician would be equivalent to what it would be if you were placed in a very good system from a safety perspective?

of course NOT....some systems REQUIRE more work....

One hospital has ALL your drugs drawn up and labelled...

different hospital...you have to draw up your own drugs and label them...


However, with the same properly trained....properly MOTIVATED individual...the safety is the same.

 

[WholeLottaGame7]

I swear, sometimes it feels like I'm reading a kindergarten forum.

That said, I don't see what all the disagreement is about. I don't think anyone is saying that if a mistake happens, that an individual isn't the proximal cause and needs to take responsibility. I also don't see how anyone can debate that systems help prevent error.

With all due respect to MMD, this is how I interpret his argument: in an ideal world, everyone could work indefinitely because they are self-aware enough to realize when the quality of care they are delivering is compromised and stop at that point. Therefore, any errors in the meantime are the result of personal fallibility and demand individual accountability.

There are a couple problems with this logic. We'll start with the assumption that a basic skillset is shared (dangerous, I know). 1) I imagine that there are very few people in the world capable of both differentiating microscopic and gradual changes in their performance at a given moment in time, and much less admit to it honestly. There is a lot of pride in medicine. 2) The medical field doesn't always permit optimal performance levels due to staffing levels of residents/attendings, much less in an emergency setting. 3) The amount of time before performance decline varies greatly from individual to individual, but work hour regulations do not distinguish this.

With regards to systems, maybe it would help to think of a system as a form of communal knowledge? For instance in the ICU example: what's the difference between the resident having an ARDS order sheet, and the attending leaving explicit written/verbal instructions before retiring to the call room? I guess you could argue that this is taking away a small slice of personal responsibility from the resident, but isn't the trade off better patient care? Why have a resident learn the hard way if it's A) going to harm a patient and B) could have been avoided?

Just my thoughts from a med student who hasn't seen it all yet...

 

[MDEntropy]

of course NOT....some systems REQUIRE more work....

One hospital has ALL your drugs drawn up and labelled...

different hospital...you have to draw up your own drugs and label them...


However, with the same properly trained....properly MOTIVATED individual...the safety is the same.

OK. So you are saying with said individual, let's call him joe, the safety is the same, but it may take joe twice as long to do his cases?

In the meantime, other individuals are less safe and they run circles around joe in terms of getting cases done.

Since major errors are so rare, it is difficult to appreciate the marginal increase in safety slow joe provides, but you can easily identify the much more apparent marginal increase in time.

Some generic system safety changes are instituted.

Slow joe is now more efficient...that is he gets his cases done as safely but in less time. Meanwhile, the fast guys running circles around joe become more safe. They still may not be quite as safe as joe (because joe has already maximized his safety and is essentially perfect from a safety standpoint), but everyone benefits, as not only is joe faster, but the non-perfect individuals have become more safe.

 

[militarymd]

OK. So you are saying with said individual, let's call him joe, the safety is the same, but it may take joe twice as long to do his cases?

In the meantime, other individuals are less safe and they run circles around joe in terms of getting cases done.

Since major errors are so rare, it is difficult to appreciate the marginal increase in safety slow joe provides, but you can easily identify the much more apparent marginal increase in time.

Some generic system safety changes are instituted.

Slow joe is now more efficient...that is he gets his cases done as safely but in less time. Meanwhile, the fast guys running circles around joe become more safe. They still may not be quite as safe as joe (because joe has already maximized his safety and is essentially perfect from a safety standpoint), but everyone benefits, as not only is joe faster, but the non-perfect individuals have become more safe.

No....personal responsibility is personal responsibility..


you are changing the premise....slick.

you are introducing the concept of "efficiency" into what I submitted as a safety issue.

I, YOU, US, should never relieve the RESPONSBILITY of safety from the INDIVIDUAL....as Gaba would have you do.....

 

[MDEntropy]

No....personal responsibility is personal responsibility..


you are changing the premise....slick.

you are introducing the concept of "efficiency" into what I submitted as a safety issue.

I, YOU, US, should never relieve the RESPONSBILITY of safety from the INDIVIDUAL....as Gaba would have you do.....

Do everyone on this board a favor and eliminate the personal attacks.

I am not sure what specifically you are saying "No" to.

Anyway, safety does not exist in a vacuum. Efficiency and production pressure play a major role in patient safety. This is a huge part of anesthesia and everyone in anesthesia knows this but it is beneficial to all the young bright minds who come to this forum need to learn about managing these complex issues in a systematic fashion.

You regularly make statements about Gaba. I suggest you read Gaba. I must assume you have not based on the things you say about his approach.

For starters, try reading the "Theory of Dynamic Decision Making and Crisis Mgmt".

I am going to quote Gaba here in response to the last line in your last comment. In the past, you have made other comments like the one I am responding to. The quote that follows is directed at "everyone who administers anesthesia." I mention this so that you have the proper context for the words "you" and "your/s"

"The responsibility for providing good patient care is yours...The burden of proof is on YOU (caps are part of the text) to ensure that the patient is safe...Your professional knowledge and skills are your most important resource...however like all resources, the self resource is neither omnipotent nor inexhaustible...your attitudes are an important component of your abilities...the invulnerability and macho attitudes are particularly hazardous."

peace

 

[militarymd]

Do everyone on this board a favor and eliminate the personal attacks.

uhh...Junior.....Why don' t YOU do everyone on this board a favor and go back to the beginning of this thread and check out just WHO started the personal attacks.

And Junior....NOTHING exists in a vacuum....However, I was discussing the issue of SAFETY as it relates to PERSONAL RESPONSIBILITY.....A concept that is going the way of the wind in the generation y's and on.

I am talking specifically about ONE concept.....and how it relates to the individual....and you are clouding this single concept with how it relates to OR efficiency...productivity....blah blah.....stuff that I have plenty of experience dealing with...having been the medical director of 2 separate 15+ OR hospitals.....but perhaps you have MORE experience....which for some reason you choose to hide from the readers.

Very simple here:

I believe in personal responsibility for safety....

You believe in spreading the wealth.....

Simple difference in opinion.....



I asked GABA to his face....should we ALWAYS LOOK at the system and NEVER the individual for cause of the safety violation....He answered in the AFFIRMATIVE....

I followed up that question with....what's the most common cause of aircraft accidents in the "system" review...per FAA.....he answered "pilot error"....

This was followed by a blank look on his face...when I raised my eye brow.....I walked away after that.


I guess we live in the day and age of JCAHO rules....time outs....nurses telling us what to do....etc. etc.....like the ICU thread...where someone complained about not being allowed to mix his own drugs while a patient spiraled towards death.......No wonder crna's tell us they can do our job....they can....they just have to follow the system...and they'll be just as safe....

"peace"

 

[MDEntropy]

uhh...Junior.....Why don' t YOU do everyone on this board a favor and go back to the beginning of this thread and check out just WHO started the personal attacks.

And Junior....NOTHING exists in a vacuum....However, I was discussing the issue of SAFETY as it relates to PERSONAL RESPONSIBILITY.....A concept that is going the way of the wind in the generation y's and on.

I am talking specifically about ONE concept.....and how it relates to the individual....and you are clouding this single concept with how it relates to OR efficiency...productivity....blah blah.....stuff that I have plenty of experience dealing with...having been the medical director of 2 separate 15+ OR hospitals.....but perhaps you have MORE experience....which for some reason you choose to hide from the readers.

Very simple here:

I believe in personal responsibility for safety....

You believe in spreading the wealth.....

Simple difference in opinion.....



I asked GABA to his face....should we ALWAYS LOOK at the system and NEVER the individual for cause of the safety violation....He answered in the AFFIRMATIVE....

I followed up that question with....what's the most common cause of aircraft accidents in the "system" review...per FAA.....he answered "pilot error"....

This was followed by a blank look on his face...when I raised my eye brow.....I walked away after that.


I guess we live in the day and age of JCAHO rules....time outs....nurses telling us what to do....etc. etc.....like the ICU thread...where someone complained about not being allowed to mix his own drugs while a patient spiraled towards death.......No wonder crna's tell us they can do our job....they can....they just have to follow the system...and they'll be just as safe....

"peace"

This thread was not the first time we interacted. I don't have a history off launching personal attacks on this forum. Despite all you have said in the past, more recently, and continue to say, I am just not going there.

Your first point: Gaba et al claim - 1) when something bad happens, it is not the individual's fault. It is the system's fault.

What Gaba has WRITTEN: "The responsibility for providing good patient care is yours...The burden of proof is on YOU to ensure that the patient is safe..."

Read that again.

"The responsibility for providing good patient care is yours...The burden of proof is on YOU to ensure that the patient is safe..."

I guess Gaba suddenly decided to change his tune when he spoke to you personally. Of course, no one can dispute that this conversation took place, and I will not. But it contradicts what he has said to thousands in the form of publication.

 

[militarymd]

This thread was not the first time we interacted. I don't have a history off launching personal attacks on this forum. Despite all you have said in the past, more recently, and continue to say, I am just not going there.

Perhaps you would like to go back and read your VERY first post to me....the dripping condescension from you , a student, to me ????

Of course you don't want to go there....the reason is because YOU were the one to launch the first salvo because YOU didn't agree with MY OPINION...to which I'm entitled to.....

Your first point: Gaba et al claim - 1) when something bad happens, it is not the individual's fault. It is the system's fault.

What Gaba has WRITTEN: "The responsibility for providing good patient care is yours...The burden of proof is on YOU to ensure that the patient is safe..."

Read that again .

"The responsibility for providing good patient care is yours...The burden of proof is on YOU to ensure that the patient is safe..."

I listened to the man...then I spoke with the man....I assessed what he said face to face...He and I had a discussion....After assessing his opinion, I WOULD never pay money or waste my time reading MORE of his opinions.

you read his book...you drank the cool aid...

As I said....I'm old school, I don't believe in "systems" that will allow MONKEYS to do things safely....I believe in CHOOSING the right people to go into our field so that the RIGHT people will do the RIGHT thing...and not be DICTATED to by protocols and "systems"..

As I said, we simply disagree....and unfortunately for me, it appears to be the wave of the future......

and UNFORTUNATELY for you, it will be a future where physician autonomy, control, and pay will be taken away a little bit at a time until you and a non-physician will essentially do the same job and get paid the same.

 

[coprolalia]

As I said....I'm old school, I don't believe in "systems" that will allow MONKEYS to do things safely....I believe in CHOOSING the right people to go into our field so that the RIGHT people will do the RIGHT thing...and not be DICTATED to by protocols and "systems"...

👍

I am all for the complete dismantling of agencies like JCAHO, who openly and actively encourage people to stop thinking and simply follow a set of instructions.

This mentality may be fine 90% of the time, but it engenders and fosters ineptitude and conflict when you are forced to go "off the script" to treat a problem that falls outside of their well-defined box. When this happens, it's surprising how few are there among the numbers of people present who actually know what to do.

-copro

 

[pgg]

Patient safety, like physical security, is most effective when organized in layers. Maybe I'm misinterpreting this thread, but I'm surprised the importance of engineering safety into a system (any system) is even debated.

Procedures and systems are important. They don't take the burden of responsibility away from the person actually delivering care, but they're not stupid touchy-feely crap either.

 

[coprolalia]

I've talked about this at length before on this forum, so I won't belabor it here. But...

The problem with agencies "overseeing" the delivery of healthcare is that they necessarily must implement a broad approach. They don't care about details. They care about uniformity, period.

The problem with failure of the system is often one of training. Whether the systematic oversight intends to or not, it takes the blame off of the individual and puts it on the system... even for individual failures. For example, the "system" didn't train you effectively, therefore we must fix it.

It doesn't take consideration for, nor does it care about, individual nuance and ability. It seeks regression to some standardized mean. And, as a dual by-product, not only can it not protect people within the system from a dangerous and determined individual (despite the belief that it can), it only serves to spread blame when a problem does arise. Furthermore, this kills innovation. Kills it.

Good intentions with bad implementation. And, agencies, like JCAHO, don't really have adequate power checks-and-balances.... which makes them, in my humble opinion, not only dangerous but somewhat terroristic.

-copro

 

[coprolalia]

In other words...

They are too busy trying to describe and mandate what is acceptable process instead of monitoring and reporting outcome.

Or, in yet even different words...

Don't tell me what to do or how to do it. Just tell me when I'm not keeping up with my peers, and let me figure out how to do better. If I need help, I'll ask for it. If I can't do better, then shut me down. In the meantime, feel free to tell me what the problem is... just not how to fix it... because I might be able to figure out a better solution than you can, believe it or not. At the very least, I should get the chance.

-copro

 

[coprolalia]

This quote nails it...

"Don't tell people how to do things, tell them what to do and let them surprise you with their results."
-George S. Patton

👍

-copro

 

[geogil]

I'm an MSIII who has a few months before my first anesthesia rotation. Correct me if I'm wrong, but isn't it true that in the past, anesthesia machines were not standardized from an engineering standpoint? On some models a dial would deliver more flow if turned counterclockwise, but on a different make, a dial in a similar position required a clockwise turn? Aren't the vaporizers now all color coded the same, regardless of who makes the machine? Aren't drug vials color coded the same accross manufacturers? Perhaps our more seasoned colleagues can think of other changes in the same vein.

It seems that these are systematic changes that have improved safety quite a bit. Even in MMD's ideal circumstances, a properly trained and well motivated individual would be statistically more likely to make a mistake if, for example, you worked on machine X all day, 25 days a month, and then on the 26th, you worked on machine Y, which, while similar, had a different setup such that some controls were reversed, as I outlined previously. The probability of making a mistake, as time increases, is simply higher than if, even at one hospital, rather than industry wide, all controls were standardized. You can argue "well, it's just good engineering" to make things standardized. That is true, but only if safety is included in the label "good engineering", which may not be true if functionality is the only thing a manufacturer is striving for. And if safety is factored into the engineering, then it's because of a systematic change, even if only at the level of the manufacturer, let alone the end-user environment.

MMD, you allude to a hypothetical error wherein perhaps 3 people are to blame. Can you explain how this is not an error in a system?

 

[militarymd]

I'm an MSIII who has a few months before my first anesthesia rotation. Correct me if I'm wrong, but isn't it true that in the past, anesthesia machines were not standardized from an engineering standpoint? On some models a dial would deliver more flow if turned counterclockwise, but on a different make, a dial in a similar position required a clockwise turn? Aren't the vaporizers now all color coded the same, regardless of who makes the machine? Aren't drug vials color coded the same accross manufacturers? Perhaps our more seasoned colleagues can think of other changes in the same vein.

It seems that these are systematic changes that have improved safety quite a bit. Even in MMD's ideal circumstances, a properly trained and well motivated individual would be statistically more likely to make a mistake if, for example, you worked on machine X all day, 25 days a month, and then on the 26th, you worked on machine Y, which, while similar, had a different setup such that some controls were reversed, as I outlined previously. The probability of making a mistake, as time increases, is simply higher than if, even at one hospital, rather than industry wide, all controls were standardized. You can argue "well, it's just good engineering" to make things standardized. That is true, but only if safety is included in the label "good engineering", which may not be true if functionality is the only thing a manufacturer is striving for. And if safety is factored into the engineering, then it's because of a systematic change, even if only at the level of the manufacturer, let alone the end-user environment.

MMD, you allude to a hypothetical error wherein perhaps 3 people are to blame. Can you explain how this is not an error in a system?

So when the nitrous interlock fails...and you accidentally deliver a hypoxic mixture to a patient and cause brain damage....

Should we blame the the system, because there was an inadequate maintenance schedule for the machine....

or the boob who didn't pay attention because he thought the machine was engineered to be dufus proof....

don't get me wrong.......developing protocols, etc. to make it harder to err is all good and fine.....but when fault occurs....we need to be finding the PERSON at fault....not the system.

Comparing us to the aviation industry is absolutely ******ed.

When pilots err....they die...when they fail simulators...they stop working.

When we err....someone else dies...and than we move on to the next victim...when we fail simulators...we still move on to to a REAL victim

 

[coprolalia]

I'm an MSIII who has a few months before my first anesthesia rotation. Correct me if I'm wrong, but isn't it true that in the past, anesthesia machines were not standardized from an engineering standpoint? On some models a dial would deliver more flow if turned counterclockwise, but on a different make, a dial in a similar position required a clockwise turn? Aren't the vaporizers now all color coded the same, regardless of who makes the machine? Aren't drug vials color coded the same accross manufacturers? Perhaps our more seasoned colleagues can think of other changes in the same vein.

It seems that these are systematic changes that have improved safety quite a bit. Even in MMD's ideal circumstances, a properly trained and well motivated individual would be statistically more likely to make a mistake if, for example, you worked on machine X all day, 25 days a month, and then on the 26th, you worked on machine Y, which, while similar, had a different setup such that some controls were reversed, as I outlined previously. The probability of making a mistake, as time increases, is simply higher than if, even at one hospital, rather than industry wide, all controls were standardized. You can argue "well, it's just good engineering" to make things standardized. That is true, but only if safety is included in the label "good engineering", which may not be true if functionality is the only thing a manufacturer is striving for. And if safety is factored into the engineering, then it's because of a systematic change, even if only at the level of the manufacturer, let alone the end-user environment.

MMD, you allude to a hypothetical error wherein perhaps 3 people are to blame. Can you explain how this is not an error in a system?

Your's is a long post (not hurling stones... clearly I live in a glass house and just pointing out the obvious...), so I'll address a couple of your points - and they are good ones, no doubt.

(1) First off, no, labeling (drug vials) is not standardized. Should it be? I don't know. Seems that people should be encouraged to actually READ the vial before they draw up the med. Standardizing would actually further discourage this practice.

(2) You're talking about technology fatigue here, nothing more. The real irony is that standardization actually can reduce vigilance, not improve it. What happens is, instead of actually learning the principle behind the machine's operation, we simply learn (or those of us less-trained) how to operate the machine. This is far different from understanding how it works, as Mil alludes to. In other words, you can put me in front of an anesthesia machine that I've never seen before and, because I understand the principle on how it's supposed to work, all I'll need is a few minutes to make it do what it's supposed to do.

Again, you can completely standardize everything if that's the goal. This kills innovation. That's the trade-off. And, I assure you that complete standardization will, overall, reduce vigilance, not improve it, and you will open a whole new set of unforeseen problems.

We're not talking about completely re-inventing the wheel and there is some value in not having to walk into a brand-new situation every day where you have to inefficiently use your time re-learning the quirks of an individual system. What we're talking about is mandating a system where you are required to follow a prescribed and predetermined course of action (at least I am), and this is slowly but surely continuing to creep into medicine.

I've been told, for example, that I can't use certain medications in the outpatient clinic. Why? Because someone above me made that determination and made it a policy. Why? Because it was their interpretation of JCAHO, the current literature, and overall ease of administrative issues far above my head. Do I like it? No. Do I have a say in changing it? Not right now. So, I deal with it, and begrudgingly follow the policy making my sometimes square patients fit into the round hole.

Is this good medicine? Maybe 90% of the time it works, but it's not really practicing medicine now, is it? Anyone can follow a protocol.

-copro

 

[pgg]

Aren't drug vials color coded the same accross manufacturers?

No, but they should be.

Along the same lines, I used to think the preprinted stickers for labeling syringes were colored in a uniform way. Blue for opiates, purple for vasopressors, red for muscle relaxants, green for anticholinergics ... then I went to a hospital where the succ stickers were purple and anticholinergics were yellow. When you've trained your brain to expect and recognize certain visual cues, changes DO increase the risk of errors.

Unfortunately, there are times when safety systems can carry the risk of diluting responsibility and increasing risk. Case in point - the all important "time out" that was supposed to put an end to wrong site or wrong patient surgeries. What used to be the surgeon's sole responsibility is now also the OR nurse's and anesthesiologist's.

I've seen one wrong site surgery, and it wasn't caught by the timeout because the surgeon wrote the wrong thing on the chart, which was copied to the anesthesia record, which the nurse read out loud in the OR. So everybody paid attention and agreed to do the wrong thing.

No substitute for vigilance.

 

[proman]

No, but they should be.

Along the same lines, I used to think the preprinted stickers for labeling syringes were colored in a uniform way. Blue for opiates, purple for vasopressors, red for muscle relaxants, green for anticholinergics ... then I went to a hospital where the succ stickers were purple and anticholinergics were yellow. When you've trained your brain to expect and recognize certain visual cues, changes DO increase the risk of errors.

Unfortunately, there are times when safety systems can carry the risk of diluting responsibility and increasing risk. Case in point - the all important "time out" that was supposed to put an end to wrong site or wrong patient surgeries. What used to be the surgeon's sole responsibility is now also the OR nurse's and anesthesiologist's.



No substitute for vigilance.

You're right, there is an international standard for medication labels:
ASTM D4774-06 Standard Specification for User Applied Drug Labels in Anesthesiology. But, it's not a universal standard, the AMA and FDA are actually opposed to the standard. Instead, they think that doing something as stupid as printing HYDROmorphone on a label accomplishes something.

 

[coprolalia]

Only part of the problem...

A systematic solution, such as this (color-coded labels), is a good idea and one we use to create a safer situation. This is an example where uniformity should supervene. However, you still have to pay attention (vigilance) to what's being drawn-up and in the appropriate concentration (etc.). You still need to look at the syringe before you give it to the patient. This is the part of the step that's often skipped/ignored because people get complacent (dare I say "lazy") with systems.

Now, couple that with the fact that the DOH later comes in and says, "Oh, by the way, you also have to time and date that sticker or we're going to write you up." They co-opt an idea that they didn't really come up with, and then try to improve on it whether or not that improvement is wanted or needed. Then, it becomes, "Oh, and you can't keep it out on top of the anesthesia machine because that's not 'secure' for that med. Someone could tamper with it or move it." This forces you to place the medications you've drawn up on your own into some place that's harder for you to get to if/when you have an emergency.

Part of implementing effective, logical systems that improve safety is knowing when enough is enough, and when you've overstepped the bounds of "safety" and are perhaps creating a new set of problems.

In other words, when you strive to make something idiot-proof they only build a better idiot. Mil and I are simply saying identify the idiots, retrain them (if possible), or get rid of them.

-copro