INTRODUCTION
A color-coding system for the pharmacological class of ophthalmic medications, along with similar corporate logos, fonts, and package sizes, has led to numerous errors with these products. Anti-infective agents are tan, steroids are pink, mydriatic and cycloplegic agents are red, beta blockers are yellow, and so on. However, individual products and dosage strengths within each [...]
Occasionally, I receive unsolicited e-mail reports from various international consulting companies and other health care-related organizations. Recently, a report from PriceWater-houseCoopers (PWC) and its Health Research Institute caught my attention.
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.
