Group #2 by https://padlet.com/cheryl_clarke/fr6vl29k7jn9 en-us 2017-01-22 22:25:47 UTC 2017-02-01 19:39:46 UTC hello@padlet.com https://padlet-assets.s3.amazonaws.com/icons/Balance.png Article #1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150952895 Error: given an abortion drug instead of antibiotic
Factors: similar name as the intended patient, didn't double check drug with patient (especially since she is pregnant)
Steps: double check that the indication of the intended drug is what the dispensed drug is too, triple check for patients who are pregnant
Tone: pharmacy did not seem overly apologetic/empathetic with the patient; seems very negative against the pharmacy]]> 2017-02-01 19:03:10 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150952895 Article 1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150952919 Pharmacist knew she was pregnant and didn't double check]]> 2017-02-01 19:03:14 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150952919 Article #2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953485 Med Error: put a paralyzing agent in the IV bag instead of the prescribed anti-seizure medicine]]> 2017-02-01 19:04:30 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953485 Article 1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953927 similar patient names -- need to verify more than just name]]> 2017-02-01 19:05:34 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953927 Article 1: Contributing factor was that patient's first and last names were similar to a different patient https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953963 2017-02-01 19:05:39 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150953963 Article 1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954329 med error = wrong medication given
Factors = similar names
For future = would put a CAP on the medication, make sure to verify address and DOB on patient when counseling also, check with patient what medication they are expecting and what it's for
4. News article is focused on the patient and the unborn baby and the effect that this medication error can have on her. ]]> 2017-02-01 19:06:17 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954329 Article 1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954673 Med Error: Wrong prescription given to patient
Factors: similar names
Steps: Ask for more than name like birth date and address, counseling on the medication
Tone: The article is focused on the patient and unborn baby, the pharmacy is not as empathetic ]]> 2017-02-01 19:07:00 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954673 Article 1: Verify patient's address and birthday rather than just their name when releasing medications https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954852 2017-02-01 19:07:19 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954852 Article 1: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954875 the response from the pharmacy was not very empathetic]]> 2017-02-01 19:07:21 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954875 Article #2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954928 not ensuring the medicines before and after compounding - computer scanning would've helped]]> 2017-02-01 19:07:28 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954928 Article 1 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954982 The patient was given chemo instead of antibiotic
Similar name
high risk paperwork not given
recheck not done
pharmacist hurried
Double check medication to order 
double check contraindications
have another person check it
Have warnings attached to high res drugs in the computer database to have alert flag when scanned
Input patient health info to trigger additional flags

]]> 2017-02-01 19:07:34 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150954982 Article #2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955115 Error: wrong medication in IV bag, paralyzing agent vs. seizure medication
Factors: human error; label on the bag was correct but not the drug inside; fire alarm caused distraction from error allowing it to be administered for a longer period of time
Steps: check drugs that are put into the bag, double check tech-work against the label/order from physician
Tone: more empathetic from the hospital than other article, deeply sorry and regretting of decision

]]> 2017-02-01 19:07:51 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955115 Art 1: pregnant woman given 1 tablet of methotrexate prescribed for different elderly patient. Human error in the pharmacy upon check out. Always counsel on methotrexate prescriptions, verify patient information first and which medication they are expecting. The article made it seem as if the pharmacist personally handed the methotrexate to the patient and I doubt that was what occurred; I would guess the pharmacist helped pick out a prenatal vitamin and the prescription was confused for another in that time. It has happened to me personally, it's not hard to do even if you're being cautious. https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955164 2017-02-01 19:07:58 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955164 Article 1: Did the pharmacist counsel on the methotrexate? If they had, patient or pharmacist probably would have realized that this medication was not the right one or was at least not appropriate for the patient to be taking while pregnant https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955583 2017-02-01 19:08:55 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955583 Article 1 hailey_jensen https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955664 Error: patient was given the wrong medication. She was supposed to get an antibiotic, but was given another patients medication on accident.
Factors: similar names, how busy the pharmacy was that day, mental status of the pharmacist (was something else occurring in their life that could have caused error), non reliant patient information for verification
Prevention: Make sure to verify more than just the patients name. Make sure the patient is fully engaged. 
Accuracy, tone, goals: The tone was very critical. They were very opinionated about the level of error this pharmacist made and how it should have never happened. The goal almost seemed to publicly shame the pharmacist and the pharmacy, especially by interviewing the patient.]]> 2017-02-01 19:09:05 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955664 Article 2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955781 hospitals response said they were not blaming one single individual, but rather everyone is to blame for not taking more precautions]]> 2017-02-01 19:09:20 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150955781 Article 2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956419 there doesn't seem to be a verification step in place to ensure that the medication inserted into the IV bag is the same on the order]]> 2017-02-01 19:10:53 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956419 Article 2 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956851 Patient was given paralytic IV rather than anti-seizure. Error made it to the patient and was not caught for more than 20 minutes so patient entered cardiac arrest and died after being taken of of life support days later. Most hospitals have scanning procedures before dispensing or compounding medications in the pharmacy. ]]> 2017-02-01 19:11:55 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956851 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956930 fairly accurate
alarmed tone
goal of raising awareness]]> 2017-02-01 19:12:09 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150956930 Article 2: Was there not a check in the IV hood or in the EMR as the IV medication was being prepared to ensure the appropriate products were being used? These could be important additional steps to take in the future to prevent mistakes like this from occurring again https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150957671 2017-02-01 19:13:44 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150957671 Article 2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150957682 Error: wrong drug in IV bag
Factors: human error, wrong medication chosen
Future: have pharmacist look more closely at the vial put into the bag, Tech double checks, extra precautions with high risk medications 


]]> 2017-02-01 19:13:46 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150957682 Article 2: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958388 Tone was much more apologetic on behalf the the hospital, voluntarily reported the errors to licensing and ]]> 2017-02-01 19:15:28 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958388 article 2 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958472 2017-02-01 19:15:41 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958472 article 2 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958542 paralytic instead of anti-seizure

human error, speed of the need
look more closely at medications, utilize computer backup]]> 2017-02-01 19:15:50 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150958542 error prevention https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966506 drugs with dosages that are an order of magnitude different (example: presnisone 5 vs 50) are easily misinterpreted; there should be an extra step in the data entry process that confirms the dose for these meds]]> 2017-02-01 19:36:50 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966506 Especially with where I work, there is no organization at the counsel window. Bags that need counsel sit on the same counter and there are no barriers between the bags. Patients may have multiple bags. Its a mess. I wish there was some type of organization to this area, which designates which bags go together and in which order. This way there isn't as many issues when the pharmacist grabs the bag and its not for the right patient. hailey_jensen https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966541 2017-02-01 19:36:56 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966541 Preventing Errors: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966551 When giving a patient their medication, make sure to have their full attention (not on phone, etc.) to make sure that you have the correct medication and they confirm that it is correct. At my pharmacy we have to verify name (with spelling), date of birth, and sometimes even address if we have multiple people with the same name in our system. Helps ensure that everything aligns properly and that the patient will be safe.

]]> 2017-02-01 19:36:58 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966551 error prevention https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966587 Be most concerned with accurate medication dispensing rather than quantity of medication dispensed]]> 2017-02-01 19:37:02 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966587 Error prevention: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966599 Using stickers or color-coding for high risk meds
Verifying info beyond patient's name and DOB at the counter
Using electronic in addition to human pre-verification and verification checks throughout the medication dispensing process
Pharmacist or additional checks in the ante and IV rooms before preparing IV medications]]> 2017-02-01 19:37:05 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966599 Preventing Errors: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966637 When checking a patient out, verify that the name, address and DOB given to you is the same on every monograph and drug in the bag.  Don't just trust the first one that you see.  This should cut down on getting a medication that is not intended for this patient to have due to a mix up of bagging medications incorrectly.]]> 2017-02-01 19:37:10 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966637 Preventing error: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966721 - Using multiple ways to verify patients identify
- Using extra precautions with high risk medications 
- checking vials of high risk medications before entering the IV room 

]]> 2017-02-01 19:37:24 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966721 Error prevention: https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966736 Making sure it is the right patient by asking birth date, relationship to patient, and address. Having a list of people for patients that are allowed to pick up their medications in the system. ]]> 2017-02-01 19:37:26 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966736 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966873 When a patient comes to pick up a medication there have been instances where I have gotten their hanging bag and there is more than one medication in it which happens to be for a different person. It is always a good idea to double check every medication in the bag just to make sure they are all for the same patient.

]]> 2017-02-01 19:37:46 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966873 Error Prevention https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966941 VERIFY and pay attention]]> 2017-02-01 19:37:55 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150966941 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967056 Be cognizant of safe working conditions in relation to staffing]]> 2017-02-01 19:38:15 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967056 Don't allow patients to call in "all" of their meds. Ask for specific names or indications for the meds or ask which meds they do not need filled to prevent filling something in their profile unnecessarily. https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967227 2017-02-01 19:38:35 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967227 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967560 verify name, address, DOB, last four of SS if applicable and available

]]> 2017-02-01 19:39:01 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967560 https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967787 Putting a note about checking DOB for patients with similar names

]]> 2017-02-01 19:39:46 UTC https://padlet.com/cheryl_clarke/fr6vl29k7jn9/wish/150967787