Showing results for 
Search instead for 
Do you mean 

Reply
Administrator
Posts: 578
Registered: ‎02-22-2010
0

Mistake Proofing for Healthcare Webinar

[ Edited ]

Thanks for joining our webinar with John Grout, "Mistake Proofing to Reduce Medical Errors."

View the on-demand recording or download the slides.

 

Have a question for John about mistake proofing? Post it here and he will answer questions for a limited period of time.

Advisor
Posts: 12
Registered: ‎05-06-2010

Re: Mistake Proofing for Healthcare Webinar

We use standardized compounding documents when we mix a batch of IV preps. The documents are pre-populated with the NDC of the most common products used to mix the prep. Beside the NDC # is a blank line for the person (technician) pulling products for compounding. The person needs to initial the line to indicate they compared the NDC on vial to the pre-populated number. This ensures the correct product is being picked. If NDC is different, they write in new NDC & initial. This prompts checking pharmacist to take a "closer" look at what was pulled. Process initiated when procainamide was picked in place of procaine. Prep was mixed & checking pharmacist missed it; fortunately another astute tech noticed empty procainamide vials in trash and knew an error had been made before prep went to the patient.

Advisor
Posts: 12
Registered: ‎05-06-2010
0

Re: Mistake Proofing for Healthcare Webinar

I have had some people refer to this process in a critical manner as "dummying up" the process. I've always took offense to this phrase, especially in healthcare when a person's health or life is at stake.

Advisor
Posts: 29
Registered: ‎07-28-2011
0

Re: Mistake Proofing for Healthcare Webinar

Excellent example, thanks! I too have heard the phrase making something "idiot-proof" but we must realize these mistakes are just us being human!