Safety and Standardization in Labeling and Repackaging
Packaging and labeling are believed to be the cause of 33% of medication errors and poor label design is cited as a potential cause. In 2016, the FDA released guidelines for safe labeling and repackaging acknowledging that improper repackaging of drug products can cause serious adverse events stating, “Because labeling, packaging, and nomenclature have been […]
Pharmacy IV Rooms: Are we minding the gap…???
Thank you to Rayburn Vrabel, former President and Principal Consultant at Vrabel Consulting Inc., and current Medication Systems Strategy Advisor, for allowing RxToolKit to publish his article, as originally seen on LinkedIn May 15, 2015, about the systems and practices that affect IV room safety. Last week in Mark Neuenschwander’s Point of Care Forum (www.pointofcareforum.com), […]
In Support of the Second Victim
Eight years after the tragic medication error that led to two-year-old Emily Jerry’s death, Eric Cropp, RPh is still distraught over the events of that day. He currently advocates for patients and caregivers involved in medication errors, and supports second-victim awareness. It has been 8 years since I made the biggest mistake of my life. […]
Insulin: One Patient – One Pen
“Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative […]
Medication Errors: “A Pharmacist’s Tale”
JDJ Consulting Founder and President John Karwoski discusses a recent near-miss medication error and the actions he took to rectify the situation. He also provides suggestions for ways to prevent medication errors and near-misses in the future. I was working at the hospital last night and caught a “near-miss.” The physician ordered a 4000 unit […]
In My Own Words: A Fatal Medication Error
In 2006, Eric Cropp, RPh lost his license, career, reputation, and more due to a fatal medication error. In his own words, Eric walks us through the events leading up to the error, the consequences, and what he thinks should be done to prevent similar events. What happened before the error? In February 2006, I […]
Medication Errors: My Near Miss
RxToolKit Founder Chuck DiTrapano shares his close-call with a medication error, what he learned from the experience, and resources for reporting errors or near-misses. About 6 years ago I was working as the IV pharmacist on second shift and I was presented with a large number of IV’s to check prior to delivery. The IV delivery […]