Revealed: NHS fails to curb lethal painkiller errors

A recent article by The Guardian points to worrying levels of avoidable patient harm in the NHS, involving strong pain killing drugs. Perhaps more alarming is the fact that some Trusts are failing to act on safety advice to reduce these errors. The article does not go as far as to link specific cases of patient harm with evidence this could have been avoided if specific points of advice had not been ignored.

It seems that human error is here to stay but its likelihood can be increased and decreased.

Left-handers vulnerable to Opticlick error

This video shows an insulin injection pen which has the potential to be read wrongly by left-handed people. The affordances of holding the pen mean it may be read upside down by left-handers, e.g. 25 for some and 52 for others. Be nice if this was considered before it went to market. Is this reasonable, who should have considered it, and what lessons have been learned for future devices?

How to set-up an infusion pump

These videos were found on the net demonstrating how to set-up different sorts of infusion pumps:

Alaris

Baxter

Plum

These are a great overview for the set-up of infusion pumps, looking at their general interaction, and noticing the tricks and checks that the nurses use for this device. If you have a look at them please share what you find interesting about their interaction in this thread, i.e. ergonomics, user experience, errors, the nurses' strategies.

Medication Errors in the under-18s

The Guardian reports that the NPSA have published their first review on patient safety among the under-18s. At least 60,000 young adults and children suffered medical errors. The excerpt below outlines some of the things that make the administration of medication problematic:

"She said nurses had to cut, crush and dissolve adult tablets and then make a difficult calculation of the dose needed by the child according to its weight.
"The doctor prescribes in milligrams but most children are given oral medicine in millilitres," she said. "Normally, the nurse has to make the calculation."
Getting the decimal point in the right place is essential, especially where the dose units have to be converted from milligrams to micrograms. A misplaced decimal point can mean a tenfold drug overdose or underdose."

Intuitively, it seems that performing multiple complex calculations involving quite variable weights in milligrams, millilitres and micrograms is vulnerable to error. Unfortunately the NPSA's data supports this.

Care Home Medication Errors

Excerpt from the website: "A study has found an “alarming” level of drug errors in care homes, The Guardian reported. The study in question looked at 256 elderly people from 55 care homes in England. The mistakes included errors in dosage and how the drugs should be taken."

Of the 256 elderly people in the study about 70% were found to have experienced medication errors. The potential harm that could be caused by these mistakes was low.

Amusing Hospital Signage

More lighthearted than usual posts: This is an amusing sign at Elhurst Emergency Trauma Center posted on failblog.

Fatal misprogrammed chemo pump taken home

This article outlines an incident where an electronic pump was taken home by a patient to recieve her chemo over a four day period, but the pump was programmed to administer the drug over four hours.

Again, and again it seems one of the messages to learn from these incidents is that they are an unfortunate combination of fairly abnormal events that would not be disastrous on their own. For example:

According to David U, President and CEO of ISMP, in this case:
"A combination of actions and conditions, which on their own would not have caused the death, happened simultaneously with tragic result."

An accident like this leads to an effort for greater learning, and we must hope that this is far reaching and lasting - but how far does this go nationally and internationally, how long lasting is it (months/years) and what are the mechanisms that faciltate this? For example, WANO is an organisation for the nuclear industry that makes announcements internationally if incidents are serious enough and others can learn from them. Could something like WANO work and be good for healthcare? This should work alongside national and local organisational learning facilities to pick up vulnerabilities and share best practice before incidents like this occur.