Archive for January, 2012|Monthly archive page

Back to the Future…

In Behavior change, High Reliability Orgs, Resiliency, Root cause analysis on January 28, 2012 at 8:08 am

ISMP newsletter, 1998

“Currently, there is no consistent process among healthcare organizations for detecting and reporting errors. Since many medication errors cause no harm to patients, they remain undetected or unreported. Still, organizations frequently depend on spontaneous voluntary error reports alone to determine a medication error rate. The inherent variability of determining an error rate in this way invalidates the measurement, or benchmark. A high error rate may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low error rate may suggest either successful error prevention strategies or a punitive culture that inhibits error reporting. Also, the definition of a medication error may not be consistent among organizations or even between individual practitioners in the same organization. Thus, spontaneous error reporting is a poor method of gathering “benchmarks;”it is not designed to measure medication error rates.” Read the full newletter here

Hey McFly, why have we made so little progress?

$9.6 million fine? will that make our blood supply safe?

In Human Factors on January 18, 2012 at 8:10 am

FDA fines Red Cross nearly $9.6 million for blood safety lapses.

FDA fines Red Cross nearly $9.6 million for blood safety lapses. Is this kind of fine realistic?  Where does the money go when the FDA receives it?

Wouldn’t losing $9.6 million seem to put the ARC more at risk for safety failures?

It seems a better process would be to shut down areas that were non-compliant until they function safely.

Read the violations here:
Some thoughts from

Caps don’t belong INSIDE patients

In Force function, High Reliability Orgs, usability on January 1, 2012 at 8:15 am

Let me begin 2012 by recommending that everyone subscribe to ISMPs safety newsletters: let that be your first New Year’s resolution in committing to make your practice safer. There is an acute care edition, ambulatory edition, nursing edition and consumer edition.  Subscribe here.

The december nursing edition (Nurse-ERR) describes a case where an ADULT patient (not a pedi patient!) was found to have swallowed one of the small white caps that covers the end of a syringe. This was discovered after the patient developed a cough after discharge. After a particularly intense coughing episode, the cap came out!   This patient had no recollection of swallowing this cap.  The newsletter recounts historical dangers associated with small parts left at the bedside of patients and their subsequent inhalation.  Of course this has always been a concern for pediatric patients but now we see the SAME RISK in adults.

Nurse ERR wisely recommends all staff scan patients’ rooms for potentially dangerous items left at the bedside and that this be added to rounding procedures by all disciplines: housekeeping, Nursing, MDs and even family and visitors. The more eyes the better.

In the spirit of this blog and its focus on human factors, I would also like to implore manufacturers of hospital products (especially IV related products with small caps and pull caps) to help eliminate these hazards alltogether by making caps that are NOT detachable.   Make all removable small pieces removable but stay attached.

It can be done for usb ports…why not do it for something that can save a life?

I always lost these caps...

This design Prevents loss of the cap!

Even better! This design prevents loss of cap and actually encourages one to recap.

Update: I emailed the ISMP asking for their advocacy in getting manufacturers to develop products that force safety in their IV supply products..then I emailed Baxter requesting they develop a product. I got a call back and they were concerned about infection and recapping but responded that they would pass this onto their engineers to see if something could be done that would attach the cap yet protect the patient from potential infection by preventing recapping. Here’s hoping they can come up something so our only safety barrier isn’t front line staff vigilance. Thanks to both these agencies for being responsive.

Remember: SPEAK UP! your ideas might just save a life!

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