Another heparin error: learning from mistakes so we don’t repeat them.
ISMP Medication Safety Alert! November 29, 2007. 1-2
I am sure we have all heard about the recent Heparin overdose of the Quaid twins as it has gained a lot of press.
ISMP's take on how to help minimize reoccurrences of such errors is for organizations to be "mindful" of safety and fully adopt a learning culture. One of the strategies they suggest to help support a learning culture is for hospitals to be vigilant about learning from error EXTERNAL to their own organizations.
This strategy is one that librarians are well situated to impact through our research and networking skills. I hope that this article and the expertise and opinion of ISMP will be useful to those of you who are advocating for a role in your organization's patient safety efforts.
Surgical fires: decreasing incidence relies on continued prevention efforts. - Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
2 days ago