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John Edem Fiadjoe's avatar

Our systems should be built for the “ pilot” having their worse day and their best day. There are several systems solutions to this error but unfortunately many centers haven’t implemented them. The mantra in medicine is try harder read the label etc those things are important but given the inherent cognitive imperfections of the human brain will never be reliable solutions. Thanks for sharing Ron

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Al Dorsey, MD's avatar

Ron,

Good case discussion, at first I was concerned about identifying the patient, but I see that with Mom's advocacy, I'm sure you have her blessing. Most institutions but not all have taken steps to avoid errors like the one you describe. Rearranging the drug layout is one. I am also a strong advocate for some automated bar-coding/drug labeling system in the OR. There are several on the market and it allows the organization to kill two birds, labeling requirements and decreasing drug swap risk, with one stone.

I would like to encourage you in your position with ISMP to encourage the pharmaceutical industry to decrease with look alike drugs and drug concentrations that have to be altered prior to use.

Al

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