tag:blogger.com,1999:blog-32053362.post6051901762438129092..comments2024-03-29T05:39:11.334-04:00Comments on Not Running a Hospital: Two drugs, one problemPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-32053362.post-92193909810777256042008-06-12T20:51:00.000-04:002008-06-12T20:51:00.000-04:00While humans make mistakes, inadequate staffing sh...While humans make mistakes, inadequate staffing should be considered to prevent such errors.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-52519290849911717822008-05-15T14:26:00.000-04:002008-05-15T14:26:00.000-04:00Most people assume that we see what there is to be...Most people assume that we see what there is to be seen by simply opening our eyes and looking. "Frank" is absolutely correct in suggesting that if one is forced to attend to the written label (as opposed to the cap color, bottle size etc) less errors would occur. The key term here is "attention." Empirical evidence bears this out - people are often unaware of surprisingly large, and potentially important events in their visual world when distracted. Indeed, studies in our lab have repeatedly demonstrated that just because an object is salient doesn't guarantee its detection. Rather, conscious perception requires attention.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-5391383675608111302008-05-15T08:30:00.000-04:002008-05-15T08:30:00.000-04:00I happen to disagree with Frank, although I see hi...I happen to disagree with Frank, although I see his point. There is ample evidence that human error, whether a "lapse" (e.g. mental slip) or "mistake" (thinking about it, but making the wrong choice through lack of knowledge or other deficiency) is inevitable and exhortations only reduce it a certain amount. In the blood transfusion arena, for instance, exhorting the lab techs to read the patient's armband when they draw the blood for crossmatching, or the nurses to identify the patient before they transfuse the unit, have only limited effect - hence the proliferation of methods designed to overcome these inevitable errors.<BR/>Similarities in drug packaging are a known source of error. (example Dennis Quaid's twins and the heparin incident.) Rather than exhorting the caregiver to read the label (which, again, has been shown to have limited effectiveness), packaging and labeling should be nationally standardized to minimize the possibilities for human error.<BR/><BR/>Having a teenaged daughter, I am just realizing that this will become even more important with today's generation of young workers who key on colors, icons and other non-verbal cues rather than words. Although Frank may think it will force them to read, they will use almost any other cue first. We readers are shrinking inexorably - patient safety experts beware.<BR/><BR/>nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-47998472128490865942008-05-15T07:11:00.000-04:002008-05-15T07:11:00.000-04:00Please see Randy Pausch's April 16 entry about the...Please see <A HREF="http://download.srv.cs.cmu.edu/~pausch/news" REL="nofollow">Randy Pausch</A>'s April 16 entry about the new bottle design used by Target pharmacies. <BR/><BR/>When I first saw that photo, I went "YIKES," recalling the similar-sized array of bottles I had a year ago; we depended on the differences in appearance. But you're right, if I'd had two similar-looking bottles, it could have caused trouble.e-Patient Davehttps://www.blogger.com/profile/11608258246509102466noreply@blogger.com