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Can You Prevent This Medical Error?

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This article presents a case study published in the Annals of Internal Medicine in 2002. An older patient was much improved after a difficult postoperative course. On the morning of her planned transfer out of the ICU, she had a grand mal seizure and died as a result of medical error. I will lead you through the case step-by-step. See if you can prevent this error from happening again. You are reading page 3 of Can You Prevent This Medical Error?. If you want to start from the beginning Go to First Page.

This wasn't done even years ago (and I'm talking three decades). The only art line I've ever pushed a med through is a UAC but that's a different animal.

If you PM me I will send you the full text article. The case I presented is from the Annals of Internal Medicine. It was published back in 2002, and describes a case that went to the JC for review as a sentinel event. "You can't make this stuff up!"

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I'd like to know what kinds of errors are killing hundreds of thousands of people. Are we talking blatant administration errors? I imagine a huge factor would be polypharmacy among the elderly population - drug interactions, inappropriate doses ordered, allergies/reactions etc. I wonder what percentage is actual nurse-given, wrong med/dose etc.

I have a course you can take for 1 CE (no charge!) that will answer your question: Safe Medication Administration: Everything You Need to Know to Improve Your Practice – COURSE for 1 CE – Safety First Nursing

but to give you the short answer: med errors, Cauti, Clabsi, wrong patient/site in surgery. It really depends on how you define the term "Error". These errors are so hard to capture because we rely on self-report. Falls, chaotic discharge...there are so many! To learn more, you can take a look at this article from Becker's review on the 9 most common med errors: 9 Most Common Medical Errors

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If you PM me I will send you the full text article. The case I presented is from the Annals of Internal Medicine. It was published back in 2002, and describes a case that went to the JC for review as a sentinel event. "You can't make this stuff up!"

Flushing with a syringe full of straight Heparin may be cited in the article but it was/is not standard of practice in any of the places I've worked. YMMV.

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Ok call me dumb' date=' What is YMMV?[/quote']

Your Mileage May Vary.

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