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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Michael Dowling is Northwell Health’s President and CEO and the Institute for Healthcare Improvement (IHI) Board Chair. In a new book, Leading through a pandemic: The inside story of humanity, innovation, and lessons learned during the COVID-19 crisis, Dowling describes how Northwell’s history of disaster preparedness was essential to their COVID-19 response. In the following interview with IHI, Dowling shares some sometimes surprising insights from an early epicenter of the pandemic.
  2. Content Article
    Guy's and St Thomas' has shared a downloadable version of the 'Big 5'.
  3. Gallery Image

    Filing

    Patient Safety Learning

    Patient Safety Learning posted a gallery image in Documentation

    Filing
    Although the drawers in this filing cabinet are labelled there is no standardisation to it. How easy is to find the drawer you want if you are in a hurry?
  4. Gallery Image
    Filing cabinet
    Untidy filing. Documents not always put away. Paper falling out of cabinet. This can makes finding documents slow and time consuming and open to error if a document is put in the wrong drawer or lost.
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    Storage trays
    These fluids stored here are all different. Although labelled, how easy is it to pick up the wrong one? Look at the red labels - is the label for the tray above or below?
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    Fluid storage
    The trap here is that the fluids stored here are all different. There is a normal saline stored next to potassium and glucose. In a hurry, the wrong fluid may be picked up and cause patient harm or even death.
  7. Gallery Image
    Prednisolone tablets
    Same medication but different doses. Easy to pick up the wrong box if in a hurry.
  8. Gallery Image
    Noradrenaline and Dexamethasone
    Almost identical packaging and labelling.
  9. Gallery Image
    Metoprolol tartrate
    Same drug, but different bottles...
  10. Gallery Image
    Metoclopramide and Pitocin
    Very different drugs, so why the similar bottles?
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    Boxes of Lisinopril
    Lisinopril tablets. Spot the pack with different dose. Very similar colours (purple and dark blue) to distinguish between 10mg and 20mg. Easy to pick up wrong pack if in a hurry.
  12. Gallery Image
    Heparin sodium and Midazolam
    Identical bottles, different medication.
  13. Gallery Image
    fentanyl v sux
    One drug is a strong pain killer used in anaesthetics (Fentanyl). The other is also used in anaesthetics and is a paralysing agent (Suxamethonium). Both look the same, same dose. Very dangerous if the wrong one is given to patient.
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    Fentanyl and glyceryl trinitrate
    Different colour rings at top of the bottles are very easy to get mixed up.
  15. Gallery Image
    Ephedrine hydrochloride and Suxamethonium chloride
    Similar boxes, different drugs.
  16. Gallery Image
    Digoxin Teva
    Same packaging and text. Why isn't the dose in a different colour so it easily stands out? Busy staff have to look very closely at the boxes to identify the difference. Mistakes could easily be made.
  17. Gallery Image
    Similar bottles
    Almost identical bottles. Same colours used on both but different drugs.
  18. Gallery Image
    Ciprofloxacin and Clarithromycin
    Almost identical bottles, same colours used for both, similar names, same dosage. How easy would it be to pick the wrong one up?
  19. Gallery Image
    Ipratropium bromide and Salbutamol
    They look identical but different drugs. Often stored in the same place. Not catastrophic for most patients if they were given by mistake but would be for patients who were allergic.
  20. Gallery Image
    Atropine sulfate and Lidocaine HCL
    Similar bottles, but different drugs. Why are the caps the same colour?
  21. Gallery Image
    Tetracaine
  22. Gallery Image
    Prescription
    An example of poor prescribing. Would you be happy to administer this medication?
  23. Gallery Image
    Handwriting
    Can you read the notes?
  24. Gallery Image
    Handwriting
    Illegible writing.
  25. Gallery Image
    Prescription
    Guess what drug is being prescribed here...
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