6 ms·

A lot of errors do seem to be this type: wrong medicine being given. The error can originate from any step of the way (doctor ordering the wrong medicine, pharm

by pen2l 10y ago

A lot of errors do seem to be this type: wrong medicine being given. The error can originate from any step of the way (doctor ordering the wrong medicine, pharmacist failing to confirm medicine being given is good or not, the nurse mistaking it, the drug-dispensing machinery involved failing, etc.). Do any HN users have thoughts on what sort of system could be put in place to minimize mistakes like this in the field?

progressive_dad 10y ago
There was a definitive study done that showed you can reduce malpractice mistakes by some insanely HUGE amount by changing 1 variable: Leave nurses alone while they're administering medicine. In the study they gave nurses "Do Not Distrub" vests where doctors (no matter how important or urgent) may not disturb the nurses while they are wearing them. Can't find the original study but here is a related piece on hospitals initiating the practice with related resources: https://www.amsn.org/practice-resources/care-term-reference/care-issues/question-do-not-disturb-vest-while-administering https://www.amsn.org/practice-resources/care-term-reference/...
deleted 10y ago
[deleted]
flarg 10y ago
I am a former pharmacist who has moved into technology consulting. I'm in the UK so forgive the UK focus of my response. It is in fact the role of a pharmacist to reduce medication errors - and this is achieved through a series of checks - largely focussed on asking 'is this the right medicine and dosage for this patient and the condition to be treated?' and 'has the correct medicine, dosage and dosage form been dispensed?' Errors tended to occur outside of pharmacy's area of control; in theatres to where pharmacists often have little access, in ward settings where medicines are administered in sometimes noisy and chaotic environments, in clinical teams where pharmacists are not allowed to have a presence, and indeed in the modern NHS where pharmacy staffing levels are severely reduced. A technological solution is possible - based on the concept of checklistbundles, patient medical and medication record systems and image scanning technology - but it is usually hard to sell clinicians on the idea of a check-list never mind anything else. Until there is a true incentive to change practices around medication administration (i.e. unlimited fines) this will always be a hard thing to change.
- noir_lord 10y ago
  The tragedy here is that checklists where invented for dealing with complex common situations under stress (iirc they where popularised not sure if invented in the modern form as a way to allow pilots to fly a much more complex aircraft than preceeding models[1]). http://www.atchistory.org/History/checklst.htm http://www.atchistory.org/History/checklst.htm
  - flarg 10y ago
    Indeed - the corresponding research into checklistbundles indicated that they would be quite effective; but I think the lack of anything like 100% uptake is due to the lack of appropriate technology to easily create, maintain and utilise checklistbundles.
    - SapphireSun 10y ago
      I really doubt that... I'm pretty sure the reason for lack of uptake is organizational and social in nature. A checklist is the simplest thing in the world. I can make a checklist right now! - Write comment (Check!) - Check grammar and spelling (Check!) - Scrub abusive language (Check!) - Click "reply"
      - flarg 10y ago
        Check-lists in medicine (and real life) are a lot more complex depending on the protocol and the patient and are more akin to complex business process flows - around which a whole industry has grown. A colleague in psychiatry spent 12 months designing a simple checklist and data collection form for initial patient evaluation.
        SapphireSun 10y ago
        Sure, but that doesn't sound like an impossible thing to deal with. There are many activities we undertake that are far more complex (collecting taxes for one!) and not every process is hard, you could hit the easy ones first. It's a question of will.
Zigurd 10y ago
Checklists. It's been thoroughly studied. It works in other disciplines. I'm amazed the malpractice insurers don't write this into their policies: Checklists done or you're uninsurable.
estreeper 10y ago
To reduce this class of errors, perhaps RFID tags could be used? If the medication is prepared in a low-distraction area and tagged there, then the person administering the medicine would scan the tag to make sure it's correct before going through with it. The person tagging the medication could still make a mistake, but it would be harder for everyone else, and perhaps during the tagging process some kind of automatic flagging could be employed if the medication doesn't seem to match the patient's problems.
- leonth 10y ago
  This is already being done in a small number of hospitals in the USA and other parts of the world. The problem is mainly the resources (money and time) needed to repackage all the drugs to their own unit doses fast enough. Most of the time a barcode / QR code / equivalent 2D printed codes suffices and is much cheaper (and more flexible) than RFID tags. However, you won't believe the kind of things that go wrong with this approach either. It's basically operating a manufacturing plant inside a pharmacy / hospital, but without presence of anyone titled "engineer". In an ideal world, the drug authority (FDA) would require all manufacturers to print proper barcodes in all unit doses at the time of manufacture.
cmiles74 10y ago
Computerized order entry of medications. Poor penmanship and unreasonably unpleasant (or unreachable) physicians is still the root cause of many erroneous orders. Even today, with the push for electronic systems, many physicians push the entry duty off on someone else thus keeping this kind of error alive.
jules 10y ago
Not taking medicine like epidural anaesthesia that isn't absolutely necessary would reduce the risk. I find the idea of spinal anaesthesia scary in general. It's poison with such a dose that it shuts essential parts of your nervous system down, but just under the dose that kills you. It's also in one of the most vulnerable places of your body, so that any mistake will likely have great consequences.

by pen2l 10y ago

progressive_dad 10y ago

There was a definitive study done that showed you can reduce malpractice mistakes by some insanely HUGE amount by changing 1 variable: Leave nurses alone while they're administering medicine. In the study they gave nurses "Do Not Distrub" vests where doctors (no matter how important or urgent) may not disturb the nurses while they are wearing them. Can't find the original study but here is a related piece on hospitals initiating the practice with related resources: https://www.amsn.org/practice-resources/care-term-reference/care-issues/question-do-not-disturb-vest-while-administering https://www.amsn.org/practice-resources/care-term-reference/...

deleted 10y ago

[deleted]

flarg 10y ago

I am a former pharmacist who has moved into technology consulting. I'm in the UK so forgive the UK focus of my response. It is in fact the role of a pharmacist to reduce medication errors - and this is achieved through a series of checks - largely focussed on asking 'is this the right medicine and dosage for this patient and the condition to be treated?' and 'has the correct medicine, dosage and dosage form been dispensed?' Errors tended to occur outside of pharmacy's area of control; in theatres to where pharmacists often have little access, in ward settings where medicines are administered in sometimes noisy and chaotic environments, in clinical teams where pharmacists are not allowed to have a presence, and indeed in the modern NHS where pharmacy staffing levels are severely reduced. A technological solution is possible - based on the concept of checklistbundles, patient medical and medication record systems and image scanning technology - but it is usually hard to sell clinicians on the idea of a check-list never mind anything else. Until there is a true incentive to change practices around medication administration (i.e. unlimited fines) this will always be a hard thing to change.

noir_lord 10y ago
The tragedy here is that checklists where invented for dealing with complex common situations under stress (iirc they where popularised not sure if invented in the modern form as a way to allow pilots to fly a much more complex aircraft than preceeding models[1]). http://www.atchistory.org/History/checklst.htm http://www.atchistory.org/History/checklst.htm
- flarg 10y ago
  Indeed - the corresponding research into checklistbundles indicated that they would be quite effective; but I think the lack of anything like 100% uptake is due to the lack of appropriate technology to easily create, maintain and utilise checklistbundles.
  - SapphireSun 10y ago
    I really doubt that... I'm pretty sure the reason for lack of uptake is organizational and social in nature. A checklist is the simplest thing in the world. I can make a checklist right now! - Write comment (Check!) - Check grammar and spelling (Check!) - Scrub abusive language (Check!) - Click "reply"
    - flarg 10y ago
      Check-lists in medicine (and real life) are a lot more complex depending on the protocol and the patient and are more akin to complex business process flows - around which a whole industry has grown. A colleague in psychiatry spent 12 months designing a simple checklist and data collection form for initial patient evaluation.
      - SapphireSun 10y ago
        Sure, but that doesn't sound like an impossible thing to deal with. There are many activities we undertake that are far more complex (collecting taxes for one!) and not every process is hard, you could hit the easy ones first. It's a question of will.

Zigurd 10y ago

Checklists. It's been thoroughly studied. It works in other disciplines. I'm amazed the malpractice insurers don't write this into their policies: Checklists done or you're uninsurable.

estreeper 10y ago

To reduce this class of errors, perhaps RFID tags could be used? If the medication is prepared in a low-distraction area and tagged there, then the person administering the medicine would scan the tag to make sure it's correct before going through with it. The person tagging the medication could still make a mistake, but it would be harder for everyone else, and perhaps during the tagging process some kind of automatic flagging could be employed if the medication doesn't seem to match the patient's problems.

leonth 10y ago
This is already being done in a small number of hospitals in the USA and other parts of the world. The problem is mainly the resources (money and time) needed to repackage all the drugs to their own unit doses fast enough. Most of the time a barcode / QR code / equivalent 2D printed codes suffices and is much cheaper (and more flexible) than RFID tags. However, you won't believe the kind of things that go wrong with this approach either. It's basically operating a manufacturing plant inside a pharmacy / hospital, but without presence of anyone titled "engineer". In an ideal world, the drug authority (FDA) would require all manufacturers to print proper barcodes in all unit doses at the time of manufacture.

cmiles74 10y ago

Computerized order entry of medications. Poor penmanship and unreasonably unpleasant (or unreachable) physicians is still the root cause of many erroneous orders. Even today, with the push for electronic systems, many physicians push the entry duty off on someone else thus keeping this kind of error alive.

jules 10y ago

Not taking medicine like epidural anaesthesia that isn't absolutely necessary would reduce the risk. I find the idea of spinal anaesthesia scary in general. It's poison with such a dose that it shuts essential parts of your nervous system down, but just under the dose that kills you. It's also in one of the most vulnerable places of your body, so that any mistake will likely have great consequences.