July 4th, 2011 by Michael Kirsch, M.D. in Opinion
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As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy, thought that one sole guy watching the radar at night was sufficient.
There are some jobs where nodding off poses no risk. Let me test my readers’ acumen on this issue. Which of the following professions would not be at risk if an unscheduled siesta occurred?
- A race car driver
- A congressman
- A circus clown (not to be confused with above listing)
- A lawyer (not to be confused with the above listing)
- A school bus driver
Let’s face it. Some folks on the job simply can’t safely snore their way through it. We don’t want Read more »
*This blog post was originally published at MD Whistleblower*
May 18th, 2011 by Linda Burke-Galloway, M.D. in Health Tips
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At one time, a hospital would be called a 24-hour institution but now it’s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists. In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, “no.”
Sign-outs, handoffs, shift changes, nurses’ report. These are the multiple names for the process where a departing provider is responsible for letting the arriving provider know what’s going on with the patient. According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mother’s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change. Read more »
*This blog post was originally published at Dr. Linda Burke-Galloway*
May 8th, 2011 by Elaine Schattner, M.D. in True Stories
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Last week I had some blood tests taken before a doctor’s appointment. I went to a commercial lab facility, one of several dozen centers for collecting specimens have opened up in otherwise-unrented Manhattan office spaces lately.
I have to say I really like getting my blood work done at this place, if and when I need blood tests. And it’s gotten better over the past few years.
First, pretty much all they do in the lab center is draw blood and collect other samples based on a doctor’s orders. So the people who work there are practiced at phlebotomy, because it’s what they do most of the time. The guy who drew my blood last week did the same a year or two ago, and he was good at it back then. He used a butterfly needle and I didn’t feel a thing.
Second, they seem organized and careful about matching specimens to patients. The man who drew my blood didn’t just confirm my name and date of birth, but he had me sign a form, upon my inspecting the labels that he immediately applied to the tubes of blood he drew from my right arm, that those were indeed my samples and that I was the patient named Elaine Schattner with that date of birth and other particulars. Read more »
*This blog post was originally published at Medical Lessons*
April 20th, 2011 by Mary Lynn McPherson, Pharm.D. in Health Tips
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Imagine your mother telling you she’s starting a new pain medicine, only to learn that she ended her life three days later due to a medication error. That’s exactly what happened to Linda Sanders, a 62 year old woman who thought she was getting the pain reliever Lyrica, but she accidently got Lamictal, an antiseizure medication. The mistake was probably caused by the similarity in the two medications names. Unfortunately, suicide is a known risk associated with Lamictal therapy.
Medication mistakes involving pain-relievers have consequences that range from inconvenient to potentially deadly. Why are errors fairly common and potentially serious with this group of medications? There are an estimated 75 million Americans who suffer with chronic pain, which results in a lot of prescriptions being written and filled for pain relievers. Also, people can react differently to specific pain medications. In fact, taking the wrong medication can make an unrelated medical condition worse, or even be fatal!
A large new research study recently analyzed over 2,000 prescribingerrors involving pain medicationsthat were caught before being given to patients that occurred at a teaching hospital. The errors ranged from doctors ordering the wrong dose of the medication or giving incorrect directions to the patients, to prescribing a medication inappropriate for a patient (patient allergic to medication). Most troubling was the fact that pain medicines with names that “look alike” or “sound alike”were also a cause of prescribing errors.
Medications whose names look similarwhen written or sound like other medication names have long been identified as a source of medication errors. The Institute for Safe Medication Practices (ISMP) even publishes a list of “Confused Drug Names.” Doctors aren’t the only ones who make medication errors because of confusing drug names. Pharmacists can accidently dispense the wrong medication, nurses can administer a drug with a similar sounding- or looking-name and patients frequently take wrong medications due to this confusion!
Looking at the list of confused drug names provided by ISMP, we see several pain medications on the list. Here’s a partial listing:
• CeleBREX (a nonsteroidal anti-inflammatory pain medication),CeleXA (an antidepressant) and Cerebyx (an antiseizure medication)
• Codeine (an opioid) and Lodine (a nonsteroidal anti-inflammatory pain medication)
• Hydromorphone (an opioid) and morphine (a different opioid)
• Lyrica (a medication for nerve-damage pain) and Lopressor (a blood pressure medication)
• Methadone (an opioid) and methylphenidate (a stimulant medication)
• Tramadol (an opioid) and trazodone (an antidepressant medication)
What can you do to minimize your risk of a medication misadventure caused by medications whose names look or sound like other medications? Here are some tips that may help:
• Ask questions. Doctors, pharmacists and nurses can make mistakes and you shouldn’t be afraid to question them.It’s your health.
• Use your health care team! Make sure your doctor and pharmacist provide important information about ALL of your medications before you leave the office or pharmacy.
• The National Council on Patient Information and Education (NCPIE) has a terrific handout of “Helpful Steps to Avoid Medication Errors” that you can print out and take with you when you visit your doctor or pharmacist.
• Make sure your doctor and/or pharmacist cover all the following points for each of your medications (and take notes for later):
o What is the name of the medicine and what is it for? Is this the brand or generic name?
o How and when do I take it – and for how long?
o What side effects should I expect, and what should I do about them?
o Should I take this medicine on an empty stomach? With food? Is it safe to drink alcohol with this medicine?
o If it’s a once-a-day dose, is it best to take it in the morning or evening?
o What foods, drinks or activities should I avoid while taking this medicine?
o Will this medicine work safely with any other medicines I am taking?
o When should I expect the medicine to begin to work, and how will I know if it is working?
o Are there any tests required with this medicine (for example, to check liver or kidney function)?
o How should I store this medicine?
o Is there any written information available about the medicine? Is it available in large print or a language other than English?
To quote the National Council on Patient Information and Education – “Educate Before you Medicate!” And if you have ANY lingering questions about your medications, call your pharmacist. It’s part of a pharmacist’sjob to answer patient questions, and it’s your health on the line!
March 9th, 2011 by LouiseHBatzPatientSafetyFoundation in Health Policy, True Stories
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This is a guest post by Dr. Julia Hallisy.
Serious infections are becoming more prevalent and more virulent both in our hospitals and in our communities. The numbers are staggering: 1.7 million people will suffer from a hospital-acquired infections each year and almost 100,000 will die as a result.
When our late daughter, Kate, was diagnosed with an aggressive eye cancer in 1989 at five months of age, our life became consumed by doctor visits, MRI scans, radiation treatments, chemotherapy — and fear. My husband and I assumed that our fight was against the ravages of cancer, but almost eight years later we faced another life-threatening challenge we never counted on — a hospital-acquired infection. In 1997, Kate was infected with methicillin-resistant staphylococcus aureus (MRSA) in the operating room during a “routine” 30-minute biopsy procedure to confirm the reoccurrence of her cancer.
Kate’s hospital-acquired infection led to seven weeks in the pediatric intensive care unit on life support, the amputation of her right leg, kidney damage, and the loss of 70 percent of her lung capacity. While most infections are not this serious, the ones that are often lead to permanent loss of function and lifelong disabilities. In the years since Kate’s infection, resistant strains of the bacteria have emerged and now pose even more of a threat since they can be impossible to treat with our existing arsenal of antibiotics.
Patients afflicted with MRSA will often have to contend with the threat of recurrent infections for the rest of their lives. These patients live in constant fear of re-infection and often struggle with feelings of vulnerability and helplessness. Family members, friends, and co-workers may not fully understand the facts and have nowhere to turn for education about risks and prevention. Loved ones may worry unnecessarily for their own safety, which can cause them to distance themselves from someone who desperately needs their presence and support.
We have the knowledge and the ability to prevent a great number of these frightening infections, but the busy and fragmented system in which healthcare is delivered doesn’t encourage adequate infection control measures, and patients continue to be at risk. A significant part of the problem is that the public doesn’t receive timely and accurate information about the detection and prevention of MRSA and other dangerous organisms, and they aren’t engaged as “safety partners” in the quest to eliminate infections. Read more »
As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy, thought that one sole guy watching the radar at night was sufficient.
