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| Avoiding Errors in Medication Orders
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Patients are at greatest risk of medication errors when drugs are ordered orally, but such errors can often be prevented using simple techniques such as a read-back confirmation, says Pennsylvania's Patient Safety Authority in its latest Patient Safety Advisory. A recent study conducted by physicians at Cincinnati Children's Hospital Medical Center found that, in 75 orders given orally, the error rate dropped from 9.1 percent to zero if information was entered into computers, read back and confirmed with physicians after orders were given. The read-back technique was recently added as one of JCAHO's 2007 National Patient Safety Goals to address error-prone procedure orders.
"Medical errors are more likely to occur with verbal orders because interpreting speech can be problematic due to accents, dialect and pronunciation," says Alan B.K. Rabinowitz, the administrator of the Patient Safety Authority. "Background noise, interruptions and unfamiliar drug names also make the problem worse. Many times the person taking the order is relying on memory to get the order right, and we've seen through our data this dramatically increases the risk of error."
To help you make verbal orders safer and reduce the risk of misinterpretation, the Patient Safety Authority has made available a toolkit that includes posters, training slideshows and a sample facility policy. Its recommendations include the following:
- Limit oral orders as much as possible. Use them only in situations in which immediate written or electronic communication is not feasible.
- Create a list of job titles authorized to give and accept oral orders.
- Mandate that the recipient immediately write down and read back oral orders and test results and that the prescriber confirm or correct by the prescriber. If there is a correction, the order should be written before it is read back.
- Use only approved abbreviations.
- Include in all oral orders the date and time the order is received, patient's name, drug name (brand or generic), dosage form (such as tablets, capsules or inhalants), strength or concentration, dose, frequency, route, quantity or duration, prescriber's name and signature of the order recipient.
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| Surgeon Fined for Leg Amputation
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The Florida Board of Medicine has penalized a West Palm Beach vascular surgeon whose varicose vein treatment mishap resulted in the amputation of a patient's left leg. Paul R. Liebman, MD, faces $8,517.41 in fines and is required to attend five hours of continuing medical education in risk management, according to the settlement.
During a May 2000 operation on 53-year-old Dianne Hedrick at Good Samaritan Medical Center in West Palm Beach, Dr. Liebman misidentified the left superficial femoral artery as the greater saphenous vein and stripped all or part of the vein, according to the administrative complaint filed with the Board of Medicine.
The board ruled that Dr. Liebman "failed to practice medicine with that level of care, skill and treatment which is recognized by a similar, reasonably prudent physician" in his failure to correctly identify the vessel to be stripped, by removing a portion of the superficial femoral artery and by failing to administer anticoagulants during the attempt to reconstruct or bypass the damaged artery.
After the surgery, Ms. Hedrick consulted with another physician due to loss of blood flow to her left leg, trauma of the femoral artery and impending gangrene of the left foot, according to the complaint. The consulting physician then performed a partial amputation of Ms. Hedrick's left leg, the board's documents show.
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| Weighing Weight Loss Surgery's Risks
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The Florida Board of Medicine has penalized a West Palm Beach vascular surgeon whose varicose vein treatment mishap resulted in the amputation of a patient's left leg. Paul R. Liebman, MD, faces $8,517.41 in fines and is required to attend five hours of continuing medical education in risk management, according to the settlement.
During a May 2000 operation on 53-year-old Dianne Hedrick at Good Samaritan Medical Center in West Palm Beach, Dr. Liebman misidentified the left superficial femoral artery as the greater saphenous vein and stripped all or part of the vein, according to the administrative complaint filed with the Board of Medicine.
The board ruled that Dr. Liebman "failed to practice medicine with that level of care, skill and treatment which is recognized by a similar, reasonably prudent physician" in his failure to correctly identify the vessel to be stripped, by removing a portion of the superficial femoral artery and by failing to administer anticoagulants during the attempt to reconstruct or bypass the damaged artery.
After the surgery, Ms. Hedrick consulted with another physician due to loss of blood flow to her left leg, trauma of the femoral artery and impending gangrene of the left foot, according to the complaint. The consulting physician then performed a partial amputation of Ms. Hedrick's left leg, the board's documents show.
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| News and Notes
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The Florida Board of Medicine has penalized a West Palm Beach vascular surgeon whose varicose vein treatment mishap resulted in the amputation of a patient's left leg. Paul R. Liebman, MD, faces $8,517.41 in fines and is required to attend five hours of continuing medical education in risk management, according to the settlement.
During a May 2000 operation on 53-year-old Dianne Hedrick at Good Samaritan Medical Center in West Palm Beach, Dr. Liebman misidentified the left superficial femoral artery as the greater saphenous vein and stripped all or part of the vein, according to the administrative complaint filed with the Board of Medicine.
The board ruled that Dr. Liebman "failed to practice medicine with that level of care, skill and treatment which is recognized by a similar, reasonably prudent physician" in his failure to correctly identify the vessel to be stripped, by removing a portion of the superficial femoral artery and by failing to administer anticoagulants during the attempt to reconstruct or bypass the damaged artery.
After the surgery, Ms. Hedrick consulted with another physician due to loss of blood flow to her left leg, trauma of the femoral artery and impending gangrene of the left foot, according to the complaint. The consulting physician then performed a partial amputation of Ms. Hedrick's left leg, the board's documents show.
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