Case 1
A physician ordered a heparin infusion with directions to follow a weight-based nomogram for laboratory monitoring and dose adjustments. Later that evening, the nomogram indicated that an intravenous (IV) bolus dose of heparin 1,700 units should be administered based on the patient’s activated partial thromboplastin time (aPTT) level.
A new Medicaid rule has retail pharmacies worried that lower reimbursements for popular generic drugs might cause their profits—and their business—to disappear. But the pharmacies had better not hold their breath as they wait for Congress to come to their rescue.
Published on July 6, 2007, the new rule essentially implements a congressional law in 2006 [...]
Problem: Over the years, numerous cases of confusion between methylpred-nisolone acetate (Depo-Medrol) and methylprednisolone sodium succinate (Solu-Medrol) have been reported. Although both forms of the product are used to treat inflammation, dosing may differ. The acetate form should never be given by intravenous (IV) administration.
PROMOTING A CULTURE OF SAFETY
A culture of fear stifles creativity and innovation, and it impedes continuous improvement by enabling defects to remain undetected—or unreported. Fear fosters gaps between “what we know” and “what we do.” To close this gap, it is imperative to promote and to support a culture in which staff members can search [...]
In October 2006, several nurses, pharmacists and providers commented that the medication error-reporting process at the Veterans Affairs-New York Harbor Healthcare System (VA-NYHHS) was lengthy and cumbersome and did not promote the reporting of all medication close calls and adverse events. The staff’s concerns were validated by the medication error-reporting data.
INTRODUCTION
According to the Institute of Medicine’s (IOM’s) 1999 report, To Err Is Human: Building a Safer Health System, between 44,000 and 98,000 patients die each year in hospitals as a result of medical errors, thereby making these misadventures the eighth leading cause of death. With an estimated cost of $17 to $29 billion each year, [...]
We studied a unique population from a large public hospital that serves an ethnically diverse and underserved population. Our cohort had greater race and age diversity than other population studies.
