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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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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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founding

Ron this is my recurring nightmare. I actually envision this situation in my sleep and wake up in a cold sweat. I have seen and photographed too many look a like vials and I have been spooked. I like the comment about how vigilance is not enough or a reliable system. I want to know how do we force drug manufacturers to be a part of the solution. Why is there no standardization of how vials look. Drugs that need to be diluted should also have a different method in how they are drawn. In my mind that would be one place where we could start. My biggest question is how can I as a practitioner do more to change the system?

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Ron, thank you for another great discussion. What a horrible case to read about. I couldn't agree more that solutions need to involve correcting the system and not just education and telling providers just to pay more attention. After many years of working in a patient safety role, I also want to stress the importance of calling risk management/ patient safety early. I have often times seen an inherent distrust or skepticism when these teams get involved. They are there to help and not blame! Even adjusting or forgiving a medical bill when an error was committed goes a long way. The bill that comes after an event can just add fuel to the fire.

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This is an anesthesiologist’s worst nightmare, we all want to take good care of our patients and try our best but as soon as we hear ASA1 we let our guard down, and the similar top vials are not helping either.

I have posted numerous pictures of the “anesthesia blues and oranges” on Twitter there has to be a change.

Besides that the Pyxis continue to have ondansetron and phenylephrine vials stocked next to each other.

Patient safety is not the sole responsibility of anesthesia professionals.

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