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I had read the order carefully, looked up the medication, and consulted with a pharmacist before giving it. Immediately, the blood rushed up from my feet to my ears, and I was lost in pounding waves of white noise. Medication errors are potentially heart stopping: figuratively for nurses, verily for patients. In nursing school, I had an instructor who said that she'd never, ever, in 30 years, made a medication error. Julianna Paradisi wants to know what you do to help minimize the risk of chemotherapy and radiation exposure. Julianna Paradisi explains about how we can maintain those healthy resolutions -- even during the cold winter season. Oncology infusion nurse Julianna Paradisi explains how the anti-vaccine trend may impact neutropenic cancer patients.
Oncology infusion nurse Julianna Paradisi explains that not all chemotherapy treatment is used for cancer.
Your private practice has decided to implement a patient navigation program specifically for high-volume patients with numerous needs across the cancer trajectory.
Participants will also be able to ask questions during a live question and answer period with speaker Ellen T. To save this item to your list of favorite TheONC content so you can find it later in your Profile page, click the "Save It" button next to the item. If you found this interesting or useful, please use the links to the services below to share it with other readers. We often note here that quality improvement in hospitals seems excruciatingly slow to happen, and engaged patients and families need to keep their eyes wide open, because sometimes a fix doesn’t require being a genius.
We’re in our 13th year after To Err, yet this morning SPM member Paul Bearman spotted this article by Maura Lerner in the Minneapolis Star Tribune and posted a note on our member listserv. What I love about the story is how intelligent change can be so wonderfully effective.   A small tweak reversed critical failures in discharge prescribing.
He and his colleagues decided to do a spot-check of 37 patients who were discharged from the hospital to nursing homes over three months in 2008 and 2009. The most common problems: Hospital physicians had prescribed the wrong doses, duplicate medications or omitted medications.
The project worked so well, Thompson said, that some doctors now call the pharmacist before they write the discharge orders. Share the Star Tribune article with your hospital (and nursing home’s) pharmacy staff. I personally know of two cases in my own family, in the past year, where medications were overlooked or wrong at discharge. Kudos to Bruce Thompson and team at Hennepin County Medical Center – and to all the people there who gladly adopted the change. The doctor’s original thought is still, in a way, being inspected by the pharmacist before the order is being written. I hope that the pharmacists aren’t continually finding and fixing the same problems, whether before or after order writing.
That pharmacist inspection step is going to be prone to failure, before or after order writing, since 100% human inspection is never 100% effective. I appreciate the efforts being made in hospitals, but what about the walking wounded in the clinics. Participatory Medicine is a model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care on all issues related to an individual's health. A case-study analysis was conducted of the revenues and expenses associated with the care of six patients with CLABIs, which found an average loss of $14,572 per case.
Nursing teams cut the incidence of pressure ulcers to 2% from 8%, preventing a projected 838 patients per year from  acquiring bedsores.
Over the same period, the hospital saw the number of [safety risk] reports increase from 2,696 to 9,277 annually.


BufferPlease consider leaving a comment or sharing this post via social media.Mark GrabanMark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Welcome to my blog, which is all about improving hospitals and other types of organizations through "Lean." Learn more.
Yes, we also have people on our team that do project work, howJordan Peck on Podcast #252 – Jordan Peck, from MIT to the VA to Maine Health Hey Tom! An example of a medication error caused by misread prescription written by physician caring for diabetes patient.
One research study revealed that the amount of medication errors and medicine mistakes involving doctor’s bad handwriting was a shocking 37 errors for 100 prescriptions (37%). Medication errors are so commonplace among medical professionals that these medicine mistakes have a nickname: they’re called an “ADE” (for “Adverse Drug Event”). Consider a case out of Texas this week, where the poor penmanship of a doctor was so impossible to read by anyone else that a patient was killed by a fatal medication error, as a kidney dialysis patient hospitalized for amputation of a toe was given 120 millimoles of potassium instead of the prescribed 20 millamoles. At trial, the doctor explained that he had decided to up the dosage from 10 to 20, and used his pen to change the “1” to a “2.” Seems like an easy enough thing to do, right? Except it was read not as “10” or as “20” but as “120” — and as a result, the 72 year old woman died from an overdose of potassium.
The jury found for the family and against the doctor this week in a jury trial; the hospital has already settled with the patient’s family. Long ago, whether or not a doctor had bad handwriting was not such a big deal, because they were always around to answer questions and oversee things.
These preventable ADEs are shameful, and rarely are they going to be freely acknowledged by the health care providers to the patient or their family.
A good piece of advice if you or a loved one has been harmed because of a medical provider’s error, is to at least speak with an experienced personal injury lawyer before you file a claim to learn about some of the issues that can arise with these claims, including the type of evidence needed to prove a claim and the type and amount of damages you can recover. If you found this information helpful, please share this article and bookmark it for your future reference. To learn about the 5 things you get when you hire Alan Sackrin, click on the "About" link above.
How Do You Know If A Business Acted Reasonably In Trying To Prevent an Office Slip and Fall Accident? How Do You Know If A Business Acted Reasonably In Trying To Prevent a Restroom Slip and Fall Accident? The hiring of a lawyer is an important decision that should not be based solely upon advertisements. Before you decide, ask us to send you free written information about our qualifications and experience. In hospitals and long-term care settings, an average of 1 medication error is made per patient every day – Annually, this translates into about 400,000 adverse drug events taking place at U.S. A significant number of medication errors also occur at pharmacies – Actually, estimates put pharmacy medication errors at about 51.5 million annually. Medication errors will likely increase in the future – as medical advancements and research uncover new drugs (or new uses for existing drugs) and as the Baby Boomers continue to age, many predict that there will be surge in the incidences of medication errors in the U.S. If you have been harmed by a medication error or any type of medical negligence, you can rely on a Portland medical malpractice lawyer at the Savage Law Firm for experienced help and aggressive legal advocacy. To learn more about our legal services and what we can do for you, call us at 503-222-0200 (in Portland) or at 206-957-7272 (in Seattle). The firm also provides service in Washington state including Seattle, Tacoma, Renton, Redmond, King County and Bellevue.
They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings.
Oncology nurses have the added stress of routinely administering medications with a lower therapeutic index and narrower safety margins to patients willingly offering their venous access.? They have faith in their oncology nurse's ability to treat them safely. I confided in her that I considered quitting, because I made med errors, and that my instructor never had. We standardized our double check into a checklist developed from the ONS Safe Handling of Chemotherapy and Biotherapies Handbook.


It’s a great example of the positive impact pharmacists can make when positioned properly in the healthcare system.
From my own experiences in a large HMO, I finding about 50% errors, and thanks to the pharmacist that caught the last one. Participatory medicine is an ethical approach to care that also holds promise to improve outcomes, reduce medical errors, increase patient satisfaction and improve the cost of care. Among patients with CLABIs, the number of deaths decreased 95 percent and the death rate decreased 69 percent, from 19 of 37 patients (51%) to 1 of 6 patients (16%). This analysis suggests that the intervention saved over $500,000 and could save $1 million by eliminating the remaining 72 CLABs cases hospital-wide. Science Daily reports that this number may be much higher, with as much as 61% of the medication errors taking place in hospitals being the result of a physician’s handwriting that is simply too hard to read correctly, or from a transcription error when someone tried to decipher what the doctor had written. When these ADEs cause serious injury or death all because someone’s handwriting isn’t legible, then it’s a real injustice since these are obviously preventable events. The doctor argued that this was not all his fault, because 120 millimoles of potassium is so over the range of acceptable dosages for a human that anyone on the hospital staff — any nurse, any lab tech, any doctor or nurse practitioner – would know (or should have known) that 120 was the wrong number. In today’s modern medical environment, doctors aren’t always hands-on with their patients, especially during their hospital stay.
If you or a loved one suspect that they have been a victim of an ADE or medication error, then you may need professional investigation and legal assistance to discover the truth and get justice.
Most personal injury lawyers, like Alan Sackrin, will offer a free initial consultation (over the phone or in person) to answer your questions. For more than three decades, our lawyers have been devoted to providing each of our clients with personal attention, respect and the highest quality legal services, and they are ready to get to work helping you secure justice. It includes monitoring lab values, confirming appropriate regimen, lifetime dose (if applicable), calculating the correct volume of medication in solution, and more. Supporting a culture of safety in the workplace increases rates of both error reporting and prevention. Of the six CLABIs that occurred, four were attributed to failures to follow specific guidelines.
Likewise, eliminating CLABIs, ventilator-associated pneumonia, and antibiotic-resistant infections caused by methicillin-resistant  Staphylococcus aureus could save a total of $10 million. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Much of the health care given to patients today is by non-physicians, who have been delegated the task of one-on-one care of the patient. Medicine mistakes and drug errors are seriously harming people and medication errors are killing patients all over the country, but the health care industry isn’t going to help victims voluntarily. This can be especially distressing to consider, as the people in hospitals and long-term care facilities (like nursing homes) tend to be among the most vulnerable people in terms of health.
We represent clients in communities in both Oregon and Washington from our offices in Portland and Seattle. So when I made a medication error as a new-grad, I was sure that I was not cut out for nursing.
More importantly, without adequate dissemination it can be difficult for other institutions to benefit from the practices reported here and ultimately to generate improvements for patients. Instead, I placed the patient's chart and the empty, pre-filled syringe in front of the charge nurse. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus. Now breathe." The pounding breakers of white noise subsided into the gentle lapping of my breathing.



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