Category: Standardize 4 Safety
Deborah Pasko, PharmD, BSPharm, MHA
I became interested in standardizing oral liquid and intravenous medication concentrations after seeing and taking care of patients that had experienced adverse events related to medication errors involving the wrong concentration of the medication. I experienced this during my tenure as a Pediatric Intensive Care Pharmacy Specialist from 2003-2009. In addition, in 2005 we purchased new syringe pumps (aka “smart infusion devices”) that could be programmed with the concentration for the practitioner so they could choose from a menu instead of programming themselves. It was starting the era of smart bedside technology and pharmacies needed to catch up to the technology.
Natasha Nicol, PharmD, FASHP
In the complex processes that make up the medication use system, every step offers an opportunity for error. Effective error reduction is possible if we look at each step and devise ways to reduce the human element, through strategies such as forcing functions (e.g., profiled automation), barriers (e.g., bar coding), and standardization.