December 3, 2018

Are We Underreporting?

According to a July 2016 Pharmacy Times article by Alan Polnariev, PharmD, MS, CGP entitled Overcoming Obstacles to Medication Error Reporting (http://ow.ly/1RH330jqiWG), as of 2013 between […]
November 26, 2018

Corrective Actions to Reduce Medication Errors

Unfortunately we all make mistakes, even physicians. So when it comes down to the care of a patient it is important to take all appropriate measures […]
November 19, 2018

Serotonin Syndrome: A Case Review

  Previously we were asked to evaluate a 50 year old patient who was admitted for chest pain and SOB. The patient had a prior history […]
November 12, 2018

Medication Error Rates

According to ISMP, “A national or other regional medication error rate does not exist. It is not possible to establish a national medication error rate or […]
November 5, 2018

Assessing Causation in a Medical Malpractice Case

Medical malpractice case reviews can present a number of challenges to all parties. This is especially true with a expert witness. On occasion, an expert might […]
October 29, 2018

Med Error Tracking Programs

Most hospitals practice continuous quality improvement and therefore have some type of medication error program in place. In many instances, we find that hospitals have an […]
October 22, 2018

Mechanism of Action: Does it matter?

Understanding the mechanism of action (MOA) of a medication can prove beneficial in understanding how the drug will behave. It also helps determine the potential for […]
October 15, 2018

Assessing Probability

There are a number of methods used to assess the probability of an event resulting from medication administration. The Naranjo Scale is perhaps the most common […]
October 8, 2018

The Unforgivable Error

In order to reduce medication errors, it is essential that they first be identified and reported, a key component of Root Cause Analysis. This process helps […]
October 1, 2018

Serotonin Syndrome: Are we missing it?

Serotonin syndrome can often go overlooked even though it can be lifethreatening if not detected in time and properly treated. The condition is caused by excessive […]
September 24, 2018

Revisiting Once Daily Dosing

  Recently we were asked to evaluate a patient  who was administered gentamicin 440 mg IV q24 hr. The patient received 5 doses prior to obtaining […]
September 17, 2018

The Swiss Cheese Model

The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each […]
September 10, 2018

Avoiding Medication Errors

An unfortunate part of healthcare involves medication errors which can occur during any phase of the distributive process. Healthcare providers are encouraged to practice Continuous Quality […]