During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities.
An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit.
In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution
Five root causes for accidental sharing of pens were identified:
knowledge gaps and practice variation
insulin storage and removal process
information technology issues including those related to barcode medication administration and the electronic health record
insulin administration workflow.
Four major interventions to address the root causes were developed and tested:
patient-specific bar coding on insulin pens
redesign of labels
systematic removal of discharged patients’ medications
ongoing staff education.
This issue (episode 2) focuses on:
the most common safety issues associated with measuring patient weight
steps to eliminate drug concentration confusion
understanding Patient Care Analgesia (PCA) by proxy.
There are currently 237 million medication errors every year. While the safety risks are small in most of these cases, for some patients there are serious risks because of errors in prescribing, dispensing or monitoring medications. NHS Digital’s newly published medications guidance aims to change this, by making sure that information about medicines can be shared digitally between systems in different care settings. This podcast talks about the real benefits this will bring, and how it will impact both clinicians and patients.