Our Blog

December 20, 2019

First Dose Levels

In an effort to achieve accuracy, oftentimes clinicians are hesitant to check first dose peak and trough levels for aminoglycosides. The tendency is to obtain peak […]
December 27, 2019

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 […]
January 8, 2020

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 […]
January 15, 2020

Medication Error Reporting

“Between January and December 1990, the number of medication error reports received per month ranged from 73 to 141. In that year the number of errors […]
January 22, 2020

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 […]
January 29, 2020

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 […]
February 12, 2020

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 […]
February 19, 2020

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 […]
February 26, 2020

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 […]
March 4, 2020

Assessing Causation: Disease or Drug?

Assessing cause and effect can often be challenging in a medical malpractice case. However, when the suspected cause involves a medication, the analysis is typically straightforward. […]
March 10, 2020

Medication Histories

Medication histories are important in preventing prescription errors and consequent risks to patients. Apart from preventing prescription errors, accurate medication histories are also useful in detecting […]
March 18, 2020

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 […]
March 25, 2020

Pharmacokinetic Dosing Errors

Medication errors associated with pharmacokinetics can sometimes get overlooked. Oftentimes, dosing errors occur but may go unreported. This can be especially true when dealing with aminoglycosides. […]