tag:blogger.com,1999:blog-7108456.post3094744260219555779..comments2007-05-30T15:39:48.607-05:00Mark Grabanhttp://www.blogger.com/profile/07953086531083611251noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-7108456.post-25098971494907977822007-05-30T15:39:00.000-05:002007-05-30T15:39:00.000-05:00"To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. "<BR/><BR/><BR/>It looks like the pharmacy isn't up to date, otherwise, the the computerized drug-dispensing machines should have kicked in and sent up the red flag, PDQ.KoKohttp://www.blogger.com/profile/07120056418308994948noreply@blogger.comtag:blogger.com,1999:blog-7108456.post-83454603659819423032007-01-27T08:11:00.000-06:002007-01-27T08:11:00.000-06:00Whenever I see medical records, handwritten by the doctor, I always note that they are almost un-decipherable, and that it's really amazing that the rate of errors made by whoever is reading them - pharmacies, nurses, etc. - is not somewhere at 50% at least. It's really amazing that with all computer technology out there, the doctor is handwriting important information where, indeed, misplaced period can take someone's life.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7108456.post-60730899215852527682007-01-25T13:54:00.000-06:002007-01-25T13:54:00.000-06:00The article made one comment that caught my attention:<br /><br />After the death, the hospital retrained nurses and tested them on calculating dosages.<br /><br />When I consulted at a nuclear facility a few years ago there was a similiar solution to a problem on lock out tag out of a radioactive area. <br /><br />A poka yoke solution could have easily solved the problem but they still insisted on training everyone. <br /><br />I wonder what the impact on a production line would be if every time there was a mistake there was a training session for all employees from all areas on the production line when 5 Why's and poka yoke could solve the problem?Craig Wollnoreply@blogger.comtag:blogger.com,1999:blog-7108456.post-72585585646634716202007-01-25T10:28:00.000-06:002007-01-25T10:28:00.000-06:00Some hospitals DO staff pharmacists out in the units. I've even heard of some that are doing away with the giant centralized pharmacy and going to multiple satellite "point of use" pharmacies throughout the hospital.<br /><br />I'm sure there are tradeoffs, but it's an interesting concept.Mark Grabanhttp://www.blogger.com/profile/07953086531083611251noreply@blogger.comtag:blogger.com,1999:blog-7108456.post-7404221489383277842007-01-25T10:16:00.000-06:002007-01-25T10:16:00.000-06:00Some time ago, I read about a study where a pharmacist accompanied a doctor on rounds. Doctors don't always know all the alternatives to drugs they are used to prescribing, and may not be as sensitized to interactions. In the study, errors fell and outcomes were better. Seems like more pharmacists at the gemba could prevent a lot of trouble. And could save the nurses a lot of running around if they had the responsibility for restocking and locating. That might save enough to pay for additional pharmacists.Karen Wilhelmhttp://www.blogger.com/profile/00972148367728596457noreply@blogger.com