All these errors happened

1
All these errors happened

• How can we learn from them?

2
Wright or right?

• The nurse asked Are you Mr Thomas?
• Wright, he answered.
• The nurse then gave Mr Wright the medications
  intended for Mr Thomas.
• Source Michael Cohen, 200 Medication Errors and
  How to Avoid Them, Springfield Corporation Pa,
  1991

3
Sorry, wrong number?

• When the nurse called the laboratory for the
  test result, the technician said 442. The nurse
  repeated 442?. The technician said yes, and
  hung up. The nurse then called the surgeon and
  gave him the same number. He, in turn, ordered
  insulin for the patient.
• Then the nurse got a call from the same
  technician. Somethings been bothering me about
  your phone call, he said. Did I tell you the
  test result was 442?. The nurse said yes.
  Well, said the technician, I meant for you to
  call extension 442 to get the result.
• Source Michael R. Cohen, 200 Medication Errors
  and How to Avoid Them, Springhouse Corporation Pa
  1991

4
Change of Instructions..an everyday story

• Instead of taking the 2 different inhalers go
  back and take your normal inhaler
• 2 puffs at the start of the day
• 2 puffs at the end of the day
• And then you can take a puff during the day.
• What he meant was you can take 1 puff as needed
  during the day. I was struggling on just the one
  during the day and feeling really bad.

5
Now and then we get things wrong

• A nurse took a telephone order for insulin, then
  transcribed exactly what she heard
• give 18 units NPH now and in 8 hours
• get a stat blood sugar
• The patient was given 18 units of insulin
  immediately and another 18 units 8 hours later,
  in error. The doctor had wanted the patient to
  receive one dose immediately, and a blood
  specimen drawn 8 hours later.
• Source Michael R. Cohen, 200 Medication Errors
  and How to Avoid Them, Springhouse Corporation
  Pa, 1991

6
Hard words?

• Cyclosporine / Cyclospasmol
• Sinequan / Sumycin
• Colace / Tolinase
• Inderal / Enduronyl