An Ounce of Prevention
With regard to birth control, an ounce of prevention may be worth 7 pounds 4 ounces of cure. In the patient care business, whether pre- or in-hospital, that same ounce of prevention may be worth someone’s life and the mental health of several providers.
A recent pharmacy error led to poor outcomes for a handful of patients who underwent routine procedures. While findings are preliminary and blame is certain to be assigned later on, the bottom line is that the system failed both the patients and providers.
Technology Proliferates
Technology has greatly enhanced healthcare and more tools are available than ever. These tools not only provide diagnostic capabilities but also enable verification of accuracy. I’m sure from the perspective of an overpaid executive, they also enable more timely billing.
Barcode scanning has been available for quite some time in the hospital and has been recently made available to prehospital providers. This has enabled field personnel to verify that an appropriate medication and concentration have been chosen. Mobile apps will also advise the exact amount of the drug to be administered and the proper dilution and drip rate if applicable.
Years ago, I managed a high fidelity simulation center with a mannequin that was capable of verifying that the proper volume of the correct drug was administered. While the technology to track the exact medication is not yet available for human patients, intelligent syringe infusion pumps can help control the dosage and timing.
Be Proactive, Not Merely Reactive
There are plenty of investigations and publicity after an untoward event occurs. This is sadly the more typical reactionary response. Much like having to start a college fund after failing to take simple precautionary measures, the aftermath of basic system inadequacies can have tremendous consequences.
The time to seek possible shortcomings or potential sources of failure is today, not tomorrow. Every program must have a system of comprehensive quality improvement. There will always be something either being done or overlooked today that can help lead to a bad outcome tomorrow.
If you don’t have a designated quality review person or team, create one. Review every case, procedure and protocol on an ongoing basis. Look for potential areas of trouble, no matter how seemingly insignificant. Do not wait for failure.
Learn from Mistakes, but Work to Avoid Them
While experience may be the best teacher, don’t wait for something bad to happen to you. Learn from others!
It’s commonly said that you should train for success. The more updated version recommends training until you can’t fail. Look at your whole system and make the avoidance of failure the goal of every part of your agency.
If you’re under the impression that having the capability to verify medications as they are administered is adequate, understand that represents shortsighted thinking. If you have not verified every drug in your armamentarium, do it now rather than finding out the hard way that something is not recognized. Ensure that every addition or replacement is also confirmed prior to stocking.
In the very appropriate words of Sammy Hagar,
“Don't wanna wait till tomorrow
So why put it off another day?
One by one, little problems
Build up, and stand in our way.”
Make your improvements right now.
