Medication Safety Alert! May 19, 2016
In this week's issue:
- Reporting and Second-Order Problem Solving Can Turn Short-Term Fixes into Long-Term Remedies
- Survey on "Use as directed"
- Safer drug storage (vial grippers)
- Could vigabatrin be confused with dabigatran?
- Liquid megestrol-metoclopramide mix-up
- Aggrastat-argatroban mix-ups
Problem: Healthcare practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work system failures that hinder patient care. A medication needed for a patient is missing on a patient care unit; an order is never received in the pharmacy; access to the automated dispensing cabinet is crowded and time-consuming; the new barcode scanner has a high rate of scanning failures; a critical drug is in short supply—the list of failures is varied and quite long, often making it difficult or impossible to execute tasks as designed.1
These system failures...