Risikostyring med rapportering af kritiske situationer. Forveksling af K-vitamin og ephedrin på en fødegang
Publikation: Bidrag til tidsskrift › Tidsskriftartikel › Forskning › fagfællebedømt
INTRODUCTION: Errors of medication are frequent causes of hazards to patients. It has been suggested that containers that look alike constitute a risk of such errors. In this article, we present an example of how reporting incidents of potential risks, can be applied in their clinical management.
MATERIAL AND METHODS: As part of a medical technology assessment project on risk management in a delivery department, the staff were encouraged to report incidents that could create a potential risk to patients. The incidents were assessed by a project group as either a general problem to patient safety or a solitary incident. If considered a general problem, procedures should be changed and implemented in the department.
RESULTS: Two incidents were reported, where ephedrine and adrenaline were found in a box supposed to contain vitamin K for new-born babies. These were considered a general problem by the project group, and the procedure for storing and managing ephedrine and adrenaline in the delivery department was changed to prevent new cases.
DISCUSSION: Near misses occur more often than actual errors, and we argue that, as they are easier to discover, it is important to learn from them and thus prevent further incidents. A forum should be set up to exchange experiences of acknowledged risks, hazards, analytical results and preventive solutions.
Bidragets oversatte titel | Risk management by reporting critical incidents. Vitamin K and ephedrine mix-up at a birthing unit |
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Originalsprog | Dansk |
Tidsskrift | Ugeskrift for Laeger |
Vol/bind | 163 |
Udgave nummer | 39 |
Sider (fra-til) | 5365-7 |
Antal sider | 3 |
ISSN | 0041-5782 |
Status | Udgivet - 24 sep. 2001 |
- Denmark, Drug Packaging, Drug Storage, Ephedrine, Epinephrine, Humans, Infant, Newborn, Medication Errors, Risk Management, Vitamin K
Forskningsområder
ID: 173052069