Errors in patient safety Flashcards
Describe three possible solutions, outlined by Noble & Donaldson, to prevent wrong route delivery medication errors, illustrating your answer with reference to vincristine
3) Drug alerts that warn healthcare institutions, medical practitioners and other relevant personnel about new risks, this would ensure anybody handling vincristine knew about the possible risks when administering vincristine.
Development of consensus and evidence-based protocols and guidelines to create a standard operating procedure that prevents against error, this could mean that there were many more points for the error to be noticed and fixed.
Physical redesign of delivery systems such that it is impossible to deliver drugs by the wrong route, this would mean it would be impossible to attach a vincristine IV syringe to a spinal needle. Therefore there would be no way that it could be administered by mistake.
Describe the five domains of failure, outlined by Noble & Donaldson, which they believe have been present in the area of intrathecal vincristine administration error
Failure to learn from adverse events, Failure of international translation Failure to achieve compliance with safety guidance Failure of investigations and enquiries Failure of solutions
