Read on Twitter
It’s easy to say, “just read the damn label”, but #anesthesia professionals *do* read the #lookalikevials, conscientiously! There will still be that 1 in 1000s time when it’s missed, and it’s not just the sole anesthesia professional to blame.
A #HumanFactors thread.
1/ https://twitter.com/apsforg/status/1194266115565854722
A #HumanFactors thread.
1/ https://twitter.com/apsforg/status/1194266115565854722
Anesthesia professionals are conscientious to a fault. This is why they are starting to demand that manufacturers and institutions set them up for success instead of disaster when it comes to #medicationsafety.
@ismp1 @FDA_Drug_Info @PIPSQC @PLAN4ZERO
2/
@ismp1 @FDA_Drug_Info @PIPSQC @PLAN4ZERO
2/
The drug on the left, phenylephrine 10 mg/ml is given in 0.1 mg doses. If a patient got the whole vial at once, that would be a 100-fold overdose! People have died from this.
3/
3/
There is no reason, in my opinion, that this vial should be exactly the same shape with exactly the same cap as a simple anti-nausea medication (4mg ondansetron) and stocked in a neighboring compartment. #lookalikevials
4/
4/
Imagine if there was no standardization where the brakes and gas go in our cars, and the pedals looked the same. If someone gets in an accident, that person is responsible, but...
5/
5/
...there would also be an outcry that the manufacturers and the government bodies that oversee them are also responsible for prioritizing the public’s health and safety. See also: Boeing 737. #HumanFactors
6/
6/
The humans of the healthcare workforce are our most precious resource. Blaming individual clinicians for enormous, system-wide weaknesses
1) won’t achieve the desired outcome
2) collectively damages clinicians’ effectiveness, esp trainees
3) ignores the role of institutions
fin/
1) won’t achieve the desired outcome
2) collectively damages clinicians’ effectiveness, esp trainees
3) ignores the role of institutions
fin/
Thank you to @APSForg @apsfsafety @DrMStiegler @sbgreenb1 @mlanefall @dremilym @Ron_George @ruthi_landau @made_in_CLE @foxerinr @hypoxicchicken & more for your tireless efforts to improve medication safety in anesthesia.
This is one of the best overviews to #HumanFactors and #SafetyScience I’ve found.
“Human failure is normal and predictable. It can be identified and managed.”
http://www.hse.gov.uk/humanfactors/topics/humanfail.htm
“Human failure is normal and predictable. It can be identified and managed.”
http://www.hse.gov.uk/humanfactors/topics/humanfail.htm
