What could go wrong?

[deleted162650]

The insanity continues:

Now there’s two phenylepherine vials that A) are colors I’ve never seen it come in before - and B) look scary similar to different drugs.

At least pharmacy is now throwing the purple sticker labels over the caps on the off color Neo.

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[narcusprince]

Of course it's a lack of attention. But that's not really the point. It's still an error with potential to cause harm.

There is a wealth of very good data, in and out of medicine, that system and engineering controls reduce errors. Including errors that humans shouldn't make, and maybe wouldn't make if they had perfect workflow habits.

Gas lines don't need pin index connectors, the O2 flowmeter knob doesn't need to be different than the air/N2O, pulse oximeters don't need to be audible. If people just had perfect workflow habits no one would hook up wall nitrous to a machine's O2 inlet, and desatting patients would be detected instantly because eyes would be glued to the monitor.

It is ridiculous that there is no industry wide standardization of how drugs are packaged. Given how many of our drugs are manufactured overseas, I understand the origin of the problem and the difficulty of the solution. But better "workflow" habits isn't the answer.

The answer is better systems. For instance, on accudose(pyxis like machine) you scan the drug and the machine prints the label. You then put the label on a syringe then draw up the drug you scanned into the syringe. The question is is pharmacy willing to spend the money on machines to improve patient safety. Dilutions are apart of our jobs. But smart systems are the answer.

 

[nimbus]

The insanity continues:

View attachment 242904

Now there’s two phenylepherine vials that A) are colors I’ve never seen it come in before - and B) look scary similar to different drugs.

At least pharmacy is now throwing the purple sticker labels over the caps on the off color Neo.

Hold on. Let me get my reading glasses.

 

[Dejavu]

That there is funny.