Non-punitive med error policy

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I have always thought that the dicsiplinary approach where med errors are tracked with sucessive reprimands and warnings given, which in theory leads to termination of the employee, was punitive and ineffective in reducing med errors. It has been suggested to me as one way to address those making med errors, but I don't see much success going this route. I think people would go underground and stop reporting errors, thus exacerbating the situation. Dealing with human error in a way that focuses also on the system, not just the user of it seems the best approach, but can't be done when punative measures discourage reporting. Not to mention the mass paranoia that it stirs up.

Love to hear anyones ideas, thoughts and solutions on dealing with this ongoing challenge.

Does anyone have the link to this?

"INFANTS' DOSES WERE 1,000 TIMES TOO STRONG" front page headline of Indianapolis Star.

"Methodist (hospital) receives heparin in identical-sized vials that contain different concentrations of the drug:10,000 units of heparin per milliliter for adults and 10 units per milliliter for infants."

To make the story short they got mixed up.

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The link I was looking for was right here at the "nursing news" thread. My question is why would they put different concentrations of a potentially lethal med in identical vials? It's almost encouraging a mistake.

Does anyone have the link to this?

"INFANTS' DOSES WERE 1,000 TIMES TOO STRONG" front page headline of Indianapolis Star.

"Methodist (hospital) receives heparin in identical-sized vials that contain different concentrations of the drug:10,000 units of heparin per milliliter for adults and 10 units per milliliter for infants."

To make the story short they got mixed up.

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