On Your Meds: Straight Talk About Medication Safety
Blog Address: http://blogs.medscape.com/onyourmeds
October 15, 2012

Making Sure Medication Safety is Not a "One Note" Metric

In complex undertakings, like delivering medication to hospitalized patients, good plans can be derailed by small missteps.  If you grew up when I did, you may remember Paul Simon singing about "50 Ways to Leave Your Lover." There's at least as many ways to leave a well-intended medication management plan behind. 

Consider: Humans can and do experience cognitive slips, trips, and lapses. There are automated snafus (like similar names or similar doses displayed side-by-side on computer screen pick lists).  Correct timing of medications-like antibiotics prior to surgery-make the difference between a hit and a "thanks for coming out today" response from critics. Clinicians can't know everything about 6,000 drugs (and in some workplaces, it's not always seen as a good...

Posted By: Barbara Olson  

September 23, 2012

Healthy work environment = Robust medication error detection


There's new research showing that healthy workplaces make patients safer. I know this because of a study, cited numerous times last week in the Twitter hashtag (#ptsafety) I monitor:

Flynn L, Liang Y, Dickson G, Xia M, Suh D. (2012). Nurses' practice environments, err...

Posted By: Barbara Olson  

September 9, 2012

How Team Briefings Can Improve Medication Safety

"Knowing is not enough; we must apply. Willing is not enough; we must do."  
- Goethe

Patient safety is about turning intention into outcome. Safety doesn’t cure cancer, but safe medication practices ensure no patient will die from an inadvertent over-dose of chemotherapy on the journey toward a cure.

Processes that i...

Posted By: Barbara Olson  

September 2, 2012

Medication Safety is a Team Sport

I started a series last week about the nature of medication errors, noting a good operative definition is necessary to scope the problem. Click [HERE] if you missed the post that suggested that we’re wrong if we try to solve problems in the medication use system like blind men feeling an elephant.  And click [

Posted By: Barbara Olson  

August 26, 2012

Medication Safety: Understanding the Beast

I've been reviewing foundational steps inter-professional teams working to improve medication safety might undertake, a search that made me think about the fable of the blind men and the elephant.  

My recollection of the story goes something like this: The men at the front end convincingly describe the elephant’s trunk or tusk or ears, which is not at all similar to what&...

Posted By: Barbara Olson  

July 29, 2012

Healthy "Threat Radar" Improves Outcomes

I came across some notes I had taken at a conference about High Reliability Organizations* addressing "stress recognition." Stress recognition* (more easily understood as “threat awareness” or "threat radar") measures individuals' abilities to detect threats that negatively impact human performance. My notes said, “Pilots with high (good) stress recognition do not mak...

Posted By: Barbara Olson  

July 22, 2012

On Sepsis: A Disease with Tragic Potential for "Wrong Time" Errors

I've been away for a couple of months on a bit of an unscheduled leave. As I was thinking about time, how long it's been since I blogged at On Your Meds and what I've been doing with my time, a story about the importance of timing for optimizing safe outcomes caught my eye.

Last week, The New York Times published a story about the death of Rory Staunton, a young boy who was sen...

Posted By: Barbara Olson  

May 21, 2012

Sleep: An Important Performance-Shaping Factor

I've learned some new things about human capacity and what boosts performance in the past month or so. Mostly what I've learned is how to improve the quality of sleep. It's important for medication safety stakeholders because adequate, good quality sleep improves the fitness of the brains that skilled humans rely on when prescribing dispensing, administering, and monitoring medic...

Posted By: Barbara Olson  

April 16, 2012

Automated Solutions: "What's In Hand and Strapped On?"

So the comment section filled up after I posted an analysis of a close call warfarin dosing error a few weeks ago. Below is #16, one of my favorite responses, written by sebastianrn, calling for more rigorous automated infrastructure to support nurses at the point of care. Sebastian writes:

"This entire situation unde...

Posted By: Barbara Olson  

April 1, 2012

Usability: A Tool to Mistake-proof Computerized Processes

Computers do most things that require rote memory and processing far better than humans. That's why  checking accounts balanced by people don't reconcile to the penny nearly as often the bank's computerized processes do. And when I say "nearly as often," I mean by a factor of thousands. Using computers to improve the safety and efficiency of medication saf...

Posted By: Barbara Olson  

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About This Blog

Barbara Olson, a registered nurse who completed a fellowship with the Institute for Safe Medication Practices, blogs about improving medication and patient safety. If you prescribe, dispense, or administer medications you'll find information to help you identify and evaluate safest medication use practices at On Your Meds. The information offered by the blog author is consistent with current safety practices and should be used to stimulate discussion and evaluation. The opinions expressed in posts represent only the thoughts of the author.

Posts address beliefs, habits, and activites that may impact safest use of medications while they are in the control of professionals and consumers. Ms. Olson assumes no responsibility for comments made by readers, none of which are moderated prior to publication. Reader comments are subject to Medscape's community code of conduct. Individuals seeking specific information about a drug's efficacy, indication, dose, or safety profile should consult an appropriate drug information resource.

Disclosure: Barbara L. Olson, MS, has disclosed the following relevant financial relationships:
Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Hospital Corporation of America (HCA) (employee); LifePoint Hospitals (employee)
Served as an officer/board member for: American Society of Medication Safety; Institute for Safe Medication Practices (ISMP)
Served as a clinical reviewer for: Institute for Safe Medication Practices (ISMP)

Poll: Which of the following is the most serious barrier that prevents you from reporting medication errors and adverse events in your workplace? I'm not sure whether an event is reportable.|I don't know how to report an event.|I don't have enough time to report events.|I am afraid that disciplinary action might result if I report an event.|I'm not expected to report close calls and actual events as part of my responsibilities.|

The content of this blog does not necessarily reflect the viewpoints of Medscape.
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