Do any HN users have thoughts on what sort of system could be put in place to minimize mistakes like this in the field?
It is in fact the role of a pharmacist to reduce medication errors - and this is achieved through a series of checks - largely focussed on asking 'is this the right medicine and dosage for this patient and the condition to be treated?' and 'has the correct medicine, dosage and dosage form been dispensed?'
Errors tended to occur outside of pharmacy's area of control; in theatres to where pharmacists often have little access, in ward settings where medicines are administered in sometimes noisy and chaotic environments, in clinical teams where pharmacists are not allowed to have a presence, and indeed in the modern NHS where pharmacy staffing levels are severely reduced.
A technological solution is possible - based on the concept of checklistbundles, patient medical and medication record systems and image scanning technology - but it is usually hard to sell clinicians on the idea of a check-list never mind anything else.
Until there is a true incentive to change practices around medication administration (i.e. unlimited fines) this will always be a hard thing to change.
- Write comment (Check!) - Check grammar and spelling (Check!) - Scrub abusive language (Check!) - Click "reply"
* you might have just increased manpower requirements across the board by about 50%
* you might have just caused patients to wait over the phone 50% longer, or queue to get their medicine 50% longer, or wait for the discharge process to finish 50% longer...
How would such technology in ideal form would be like ? and how do current practical implementations look like ?
Have the system then sync that to a central system so you have a real time status of every procedure/drug/intervention administered to a patient, voice control means no issues with hand contamination, paperwork to carry around (and forget) etc.
I think we'll probably get to that at some point especially if sub-vocal voice recognition catches on.
Sure, caregivers can resent the patients asking too many questions, but this is more about setting up a collaboration and understanding the rationale behind decisions. This catches all sorts of errors that arise; it's not that the caregivers are incomptent, but they are human.
I don't doubt your intent is good, and I like to promote literacy in care as well, but I really really think the notion that supervising one's own care is a good idea is completely out to lunch. The pain, discomfort, emotional trauma, precarity -- these very real things tend to put even the best manager off one's game.
One of the most important questions you can ask your doctor before getting treatment (whether that treatment is surgery or medication) is "What happens if we don't do anything? If we just watch and wait?"
Here's a short film about involving older people, and their carers, in their healthcare when they enter a carehome setting. This work focusses on a medication review involving a doctor, a pharmacist, the patient, and their carers. The reviews save money, increase quality of life, and reduce risk of death by suicide and accidental death.
But it is seriously wrong to assume the patient will continue to act akin to a corporate employee bloodlessly toiling on a project at work. It is far more likely that the patient will at some point begin to act like a person with discomfort, with all the accompanying bewilderment, skepticism, confusion, hypersensitivity, etc. This reality needs to be honored, not waved away.
Again, I do advocate for educated and engaged patients, but I totally reject the idea that systematically these patients are to be depended upon for engagement in their own care to the degree that any medical errors can reasonably be precluded by such engagement. Not only does it fly in the face of psychological realities of patients, it appears to me to be an ugly slippery slope toward the direction of general victim-blaming and "externalization" that the corporate ethos is so well known for.
I upvoted your comment. There are a couple of things you ought to consider when reading the replies.
1.) People want to believe that they'll know when they're "off their game". That doesn't make them brutalist thugs. There's plenty of cognitive bias to go around.
2.) Saying it is "out to lunch" to manage one's own care is lacking in the context department. It seems to me that there are plenty of situations where the patient is in a strong position to "manage" their own care. Is that always the case? Certainly not, but it's not patently false. It depends.
There's been talk in the comments on this story about modern aviation, copilots. The relationship between a patient and provider ought to be adjusted to find the best outcome. Finding the right mix is difficult, but I think we can do better than "The patient is always right" or "The provider has absolute control."
I hypothesize that fewer avoidable mistakes will be made, due to care-providers exercising more caution while under the strict scrutiny of your trustee. If they know anything at all about medicine, the outcome is likely to be even better.
https://www.amsn.org/practice-resources/care-term-reference/...
Even today, with the push for electronic systems, many physicians push the entry duty off on someone else thus keeping this kind of error alive.
However, you won't believe the kind of things that go wrong with this approach either. It's basically operating a manufacturing plant inside a pharmacy / hospital, but without presence of anyone titled "engineer".
In an ideal world, the drug authority (FDA) would require all manufacturers to print proper barcodes in all unit doses at the time of manufacture.