Merrill thanks for this. The reality is workers go around the control systems and processes all day every day because patients need those medications immediately and the systems are cumbersome slow and hard to use. So…they get bypassed.
Just as problematic, reports indicate Vanderbilt failed to require patient ongoing monitoring for BOTH medications- the one ordered and the one dispensed. This is standard practice in many facilities - but evidently not at Vandy.
Lastly, error reporting will absolutely disappear due to this.
This will do more damage to patient safety than I can imagine.
Goozner makes an exceedingly valuable point which has a bit of personal connection. I had a friend whose husband died as a result of a medication error in a well-known Sacramento Ca. hospital. It was devastating, obviously. But she was also a sensitive and reasonable person who asked within a day of the death about the emotional well-being of the nurse and took steps to assure that the nurse received counseling. Her actions surprised me a little but also served as an example for many of the reasons cited by Goozner. A somewhat related example involved my brother who was a civilian oceanographer with the U.S. Navy. His duties were generally classified but he told me about an incident that rankled him for years. As his ship was mapping the Pacific Ocean bottom, a reading popped up that indicated a hazard but quickly vanished. He wanted to return to that point to ascertain whether it was a technical anomaly or an underwater danger that nuclear submarines needed to avoid. Despite considerable discussion, he did not prevail. I was reminded of this when I read about a U.S. nuclear submarine that smashed into a seamount in the Pacific at a speed of 33 knots in 2005.
Error reporting is critical whether it is a medical care situation or a nuclear submarine.
Merrill thanks for this. The reality is workers go around the control systems and processes all day every day because patients need those medications immediately and the systems are cumbersome slow and hard to use. So…they get bypassed.
Just as problematic, reports indicate Vanderbilt failed to require patient ongoing monitoring for BOTH medications- the one ordered and the one dispensed. This is standard practice in many facilities - but evidently not at Vandy.
Lastly, error reporting will absolutely disappear due to this.
This will do more damage to patient safety than I can imagine.
Goozner makes an exceedingly valuable point which has a bit of personal connection. I had a friend whose husband died as a result of a medication error in a well-known Sacramento Ca. hospital. It was devastating, obviously. But she was also a sensitive and reasonable person who asked within a day of the death about the emotional well-being of the nurse and took steps to assure that the nurse received counseling. Her actions surprised me a little but also served as an example for many of the reasons cited by Goozner. A somewhat related example involved my brother who was a civilian oceanographer with the U.S. Navy. His duties were generally classified but he told me about an incident that rankled him for years. As his ship was mapping the Pacific Ocean bottom, a reading popped up that indicated a hazard but quickly vanished. He wanted to return to that point to ascertain whether it was a technical anomaly or an underwater danger that nuclear submarines needed to avoid. Despite considerable discussion, he did not prevail. I was reminded of this when I read about a U.S. nuclear submarine that smashed into a seamount in the Pacific at a speed of 33 knots in 2005.
Error reporting is critical whether it is a medical care situation or a nuclear submarine.