Group #1 by https://padlet.com/cheryl_clarke/9lizgkw5jvx9 en-us 2017-01-22 22:22:22 UTC 2017-02-01 18:56:26 UTC hello@padlet.com https://padlet-assets.s3.amazonaws.com/icons/Babyhead.png Article https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150936970 Wrong medication was given
Patients were mixed up and thats why this patient received the wrong drug
The directions of the med were typed in as daily instead of once weekly]]> 2017-02-01 18:24:49 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150936970 Article 1. pharmacist wasn't actively thinking about contraindications https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937421 2017-02-01 18:25:51 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937421 pharmacist wasn't actively thinking about contraindications: methotrexate given to a person looking at prenatal vitamins https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937510 2017-02-01 18:26:03 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937510 article 1. didn't confirm date of birth? https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937739 2017-02-01 18:26:31 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150937739 article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938190 pharmacist did not verify pt date of birth, address or phone ]]> 2017-02-01 18:27:33 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938190 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938194 2017-02-01 18:27:33 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938194 Article #1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938198 The problem was the patient was given the wrong patien's medication. This could have been because of a tech or pharmacist not checking the birthdate and making sure it was the right patient. This article made it seem like it was an abortion pill when really theres just a chance for birth defects]]> 2017-02-01 18:27:33 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938198 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938215 Pharmacist did not take the time]]> 2017-02-01 18:27:35 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938215 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938277 Pharmacist should have checked the medication. and ]]> 2017-02-01 18:27:42 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938277 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938352 Pharmacist should have checked the medication. ]]> 2017-02-01 18:27:51 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938352 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938720 2017-02-01 18:28:35 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938720 article 1. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938828 it could be OK since the pt only take 1 pill.
actions should be taken right away to prevent further complications]]> 2017-02-01 18:28:46 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938828 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938917 Did pharmacist offer to counsel? If so, he might have caught the mistake then]]> 2017-02-01 18:28:57 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938917 Didn't double check the right medication was given to the right patient https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938940 2017-02-01 18:29:00 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150938940 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939163 Pharmacist should have verified the name, address, and birthday to make sure the patient was correct. She also should have been counseled since it was a new medication. They could have caught the error there if they had. Also double checking any contraindications with prescribed medicines and OTC recommendations. ]]> 2017-02-01 18:29:25 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939163 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939268 The pharmacist should have taken more time to grab the bag with her name, not the very similar name he did grab. However, it was probably also a structural issue of the pharmacy, because they should have had a better way to differentiate such similar names. ]]> 2017-02-01 18:29:38 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939268 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939405 2017-02-01 18:29:55 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939405 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939423 The article also mentions incorrect directions on the methotraxate prescription]]> 2017-02-01 18:29:58 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939423 The pharmacy responded properly by offering to pay medical expenses https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939594 2017-02-01 18:30:24 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939594 Article 1 the pharmacist should have counseled regardless of what the patient said since it is a 'high alert' drug https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939876 2017-02-01 18:31:11 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150939876 Should've said what the methotrexate was used for. It would have led to the patient asking about the antibiotic. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940042 2017-02-01 18:31:45 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940042 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940114 The pharmacist only asked for patient name, instead of verifying a second identifier (address, phone number, date of birth, even middle initial)]]> 2017-02-01 18:31:57 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940114 article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940328 wrong medication was given
the two patients were mixed up
the directions were typed in as daily instead of weekly]]> 2017-02-01 18:32:37 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940328 Article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940580 Unclear exactly where the error occurred. Did he look up the wrong name in the system? Or grab the wrong bag?]]> 2017-02-01 18:33:16 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940580 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940783 Wrong medication was put in an IV bag. Possibly vials that were near each other got mixed up or mislabeled.]]> 2017-02-01 18:33:45 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940783 article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940863 double check name and date of birth
tallman font
double check the directions written on the hard copy if needed]]> 2017-02-01 18:33:57 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940863 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940992 The pharmacist could have payed more attention when verifying what was in the bag]]> 2017-02-01 18:34:21 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150940992 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941014 A patient recieved the wrong drug because the wrong drug was placed in the IV bag but labeled correctly. This was an error on the tech who made the bag and the pharmacist not double checking what was put in it. This problem was made worse because the fire alarm made the nurse shut the door. This article was good because it included the offical press release which detailed what happened.]]> 2017-02-01 18:34:23 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941014 article 1 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941290 the news article clearly took the patients side. Safeway atleast sounds like they will do everything in their power to help this patient down the road, but thats the least they can do]]> 2017-02-01 18:35:02 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941290 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941668 Really highlights the severity of medication errors and serves as example as to why we need to be cautious when filling medication orders. ]]> 2017-02-01 18:36:22 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941668 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941749 Handled the situation professionally. Didn't blame certain caregivers, put procedures in place to avoid the same errors in the future, and gave an apology speech/letter]]> 2017-02-01 18:36:35 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941749 article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941859 the staff should not have left the patient unattended and uncared for while the fire alarm was going on, it took them 20 minutes to notice the error - better systems need to be in place to prevent this]]> 2017-02-01 18:36:53 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941859 article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941957 Both the tech and the pharmacist could've been more careful in double-checking the bags. But also it would be interesting to see a scanning system or electronic double-check in nuclear pharmacy]]> 2017-02-01 18:37:12 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941957 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941966 The article said the bag was labeled correctly but the incorrect drug was put in it and when it was verified it was checked with the incorrect vials. I'm curious how they missed this in the verification step.]]> 2017-02-01 18:37:13 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941966 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941988 I am curious why when the pharmacist checked what the tech did, the tech didn't have the bottle of  rocuronium and the syringe he/she used to draw it up. That shows there could be a structural issue if the tech isnt requried to do that. ]]> 2017-02-01 18:37:16 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150941988 When verifying, should have all of the materials that were used along with it, especially the bottle of the drug. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942318 2017-02-01 18:38:06 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942318 article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942347 the wrong med was given to the patient
the fire alarm went off and the patient probably wasnt being watched as closely
the drugs arent even close in name]]> 2017-02-01 18:38:09 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942347 Article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942477 having a barcode scanning system in place with the vials before putting it into the IV bag may have helped with having multiple processes in place to make sure the right med was administered, rather than relying solely on the pharmacist to check it]]> 2017-02-01 18:38:32 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942477 Article 2. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942667 Honest and empathetic about mistake made but still frame it as a problem that is being addressed with the health system and not the fault of one or two employees]]> 2017-02-01 18:38:57 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942667 article 2 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942845 human distraction
potentially not being fully alert
not double checking the vial (both by the pharmacist and the tech)

]]> 2017-02-01 18:39:24 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150942845 Article 2. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150943049 It's possible they are understaffed leading to increased hours which sometimes result in more errors]]> 2017-02-01 18:39:58 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150943049 Always double check. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948655 2017-02-01 18:53:57 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948655 my pharmacist asks during counseling "what are you using this medication for?" https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948679 2017-02-01 18:53:59 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948679 we always check name, date of birth, and address with patients since we have a few people that have the same names and/or dates of births https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948817 2017-02-01 18:54:17 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948817 Good Idea https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948903 Do your best to learn their name or generally which chronic disease(s) they have.]]> 2017-02-01 18:54:29 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948903 https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948914 Asking the patients what they are taking their medication for and what they know about it already]]> 2017-02-01 18:54:31 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948914 At my IPPE last year, I was observing someone in the IV hood who stuck themselves with a needle. They immediately were more worried about their job and the extra work they had to do rather than reporting the incident and learning from it. Creating an environment where techs and pharmacists aren't afraid to report their mistakes is pretty important. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948930 2017-02-01 18:54:33 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948930 Bringing refrigerated prescriptions to the pharmacist to get a second look to make sure the prescription matches the patient before sending it out. https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948985 2017-02-01 18:54:42 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150948985 There were a couple of issues in my pharmacy where patients were given meds for a different patient, because technicians were pushing buttons for the patients to override systems in place on the pen pad when checking out. My pharmacy printed off our procedures and had everyone sign off that they read them https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949016 2017-02-01 18:54:46 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949016 People always hold the vial of drug and the amount drawn up and have the pharmacist verify it before it gets added to a bag https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949114 2017-02-01 18:54:56 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949114 after a counseling session about how to you an inhaler the patient decided she didn't want it and the pharmacist did not try to convince her to get it https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949418 2017-02-01 18:55:36 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949418 We always give the stock bottle to the pharmacist when filling liquids and ask the pharmacist to double check when we bubble something that came through central fill https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949606 2017-02-01 18:56:05 UTC https://padlet.com/cheryl_clarke/9lizgkw5jvx9/wish/150949606