Archive for February, 2013|Monthly archive page

No med is safe…

In adverse events on February 14, 2013 at 6:14 pm

As a society i think if we want to improve safety we really have to decrease our dependence on medications.

From fox news: “Samantha was 7 when she was given Motrin brand ibuprofen, family attorney  Brad Henry said. She suffered a rare side effect known as toxic epidermal  necrolysis and lost 90 percent of her skin and was blinded, he said.

She suffered brain damage that “thankfully” involved only short-term memory  loss, he said, and surgeons had to drill through her skull to relieve some  pressure.

The disease also seared Samantha’s respiratory system, and she now has just  20 percent lung capacity, Henry said.

The family filed the lawsuit in January 2007, claiming that Samantha was  blinded by Motrin and alleging that Johnson & Johnson failed to warn  consumers that the drug could cause life-threatening reactions. The five-week  trial ended on Wednesday when the jury awarded $50 million in compensatory  damages to Samantha and $6.5 million to each of her parents.”

Read more:

Fox says they know of 20 other children this has affected 😦

Fake Fixes

In High Reliability Orgs, Patient Safety, Safety climate on February 5, 2013 at 12:07 pm



Read this op-ed piece from the Times by the author of “Bad Pharma…”

(Ben has an interesting website:

How should we handle omission of information?

Is dont ask dont tell dangerous for healthcare?

some hightlights from op-ed:

“Trials with positive or flattering results, unsurprisingly, are about twice as likely to be published — and this is true for both academic research and industry studies”

“These problems would be bad enough on their own, but they are compounded by a generation of “fake fixes” that have delivered false reassurance, and so prevent realistic public discussion.”

“All of these problems are perhaps best illustrated by the case of Tamiflu, which governments have spent billions of dollars stockpiling, in the belief that the drug will reduce the rate of complications from influenza. But roughly half the trial results have never been published, and researchers trying to obtain the full Clinical Study Reports have been stonewalled by the manufacturer, Roche.”

“This cannot be acceptable. Withholding data not only misleads doctors and patients; it’s an insult to the patients who have participated in clinical trials, believing that they were helping to improve medical knowledge.”


Do as I say not as I do

In Behavior change, Human Factors on February 3, 2013 at 12:01 pm

As healthcare workers, we are not always role-models for health. In a canadian survey 66% of healthcare workers were overweight and 18% smoked.

Do we eat breakfast?  Many healthcare workers who have children know that having  breakfast before school improves performance.

Boschloo, et al. (2012) studied kids age 11-18.  In their results, they found that habitual  breakfast skippers performed more poorly in school than habitual breakfast eaters.  Performance was measured by school grades and an attention scale. This effect was true for kids regardless of chronotype (day person or night owl).

Other studies have shown lack of breakfast can affect memory (particulary verbal in girls), mood and attention.

This research comes from the relatively new field of Mind Brain Health and Education which attempts to cohort the best research from psychology, neuroscience and education to facilitate the teaching and learning of our children, with the goal of every child reaching their full potential.  Perhaps patient safety might benefit if we use some of this research to help healthcare workers reach their full potentials?

Let’s start by making breakfast a habit for all healthcare workers!


(in a future post I will present some research on food types and Mind Brain Heath and Education)

Boshloo, A. et al., (2012). The relation between breakfast skipping and school performance in adolescence. Mind, Brain, and Education, 6(2), 81-88

Find the mistake

In adverse events, human error, Human Factors, Root cause analysis on February 2, 2013 at 5:56 pm


This mini human factors test is going around Facebook.
Once you find the mistake it becomes almost impossible not to see it.

This illustrates two concepts
1) we see what we expect to see and our brain “corrects” what does not conform and therefore we can easily misread labels
2) Only hindsght is 20/20. When investigating an error after the fact, hindsight bias may cause one to think the error was foolish and was easy to detect at the time. Now that you see the error in this little picture it seems to be so evident that you wonder how it could have been missed initially

This is why we need barcode medication identification systems for preparation and administration.
And this is why it is so important to understand what was actually known at the time of an error and not what we know in hindsight. Many errors occur when people are doing what they always have done. Usually there is no significiant deviation from norm.

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