A 55 year-old female underwent surgery to place a spinal cord stimulator. Original
post-op order at 4 pm was for "Decadron 4 mg IV every 6 hours for 24 hours." However, the surgeon came back at 9 pm and discontinued the previous order and wrote a new order for "Decadron 4 mg IV every 6 hours." The pharmacist apparently did not notice the difference in the two orders and thought it was just a duplicate of the original order, and the nursing staff did not catch the pharmacist's mistake. Therefore, the patient's Decadron was discontinued at 4 pm the day after the surgery and the error was not noted until the patient had not had any Decadron for approximately 40 hours. The malpractice complaint alleges that because the post-op swelling around the spinal cord at the area of the surgery was not sufficiently treated with the Decadron the patient was left with residual neurological deficits in one leg and foot.
In the claim described above, what we have is essentially a matter of human error.
The things could have prevented this include: the use of CPOE by physicians; 24 hour record reviews by the nursing staff; and/or review of orders by nursing staff (on coming and off going shifts together) at shift change as a part of the handoff process. Had the physician been using a CPOE system, the original order would have been discontinued in the EHR by the physician altogether and reordered as indicated or the original order would have been revised through a change option. Although systems differ in how this would be handled, the original order would have needed to be addressed by the physician. CPOE has the potential to reduce medication errors by 55-80% when used in the proper manner. The use of CPOE is listed as one of AHRQ’s and the purposeful use of CPOE is also included as an objective for meaningful use of electronic health records. Therefore, al hospitals should be working toward successful and consistent implementation of CPOE for the safety of patients. CPOE has a strong error reduction potential by reducing errors associated with transcription and illegible handwriting. Many hospitals are still struggling to get the physicians on board with the use of CPOE. Some still aren’t using it all and others are using it inconsistently. In order for CPOE to be successful it is imperative to have strong support from leadership, involvement of the medical staff from the beginning, support readily available when CPOE goes live, and training of all staff who will be involved with CPOE. It is also recommended that investigation of adverse events involving medications include an evaluation of CPOE use and if its use or non-use could have been a contributing factor. This information should be communicated to the Risk Management Other considerations to help reduce the risk of adverse event such as this one, is a thoughtful review of orders by nursing staff every 24 hours. Most hospitals have a process in place in which a nurse reviews the previous 24 hours of orders at night and compares it with the medication administration record (MAR). However, the nursing staff needs to have a good understanding of the purpose of the review in catching errors. In the claim described, had the physician been al owed to order the medication twice via CPOE, both orders would have showed up on the MAR and should have been identified at that point. Another consideration would is to have a review of the daily orders as a part of handoff nursing report between the off going and on coming shifts. As a part of the handoff, the nurses caring for the patient would review any physician’s orders from the previous shift together. This process just adds another layer of risk reduction effort. Should you need additional information or resources about this topic or other Patient Safety needs please contact our staff below. Stacie Jenkins, RNC, MSN Barbara Voinche', RN Mike Walsh, AIC, CPCU Director of Clinical RM Clinical Risk Consultant Liability Claims Manager

Source: http://lhatrustfunds.com/images/uploads/sl-lha//November.pdf


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Microsoft word - 02 - commercial feed.doc

Subpart 3-Bureau of Plant Industry Chapter 02- Commercial Feed Definitions and Terms 100.01 The names and definitions for commercial feeds shall be the Official Definition of Feed Ingredients adopted by the Association of American Feed Control Officials, except as the Commissioner and State Chemist designate otherwise, in specific cases. 100.02 The terms in reference to commercial feeds shall b

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