Response

In response to the fatal medication error in Indianapolis, our unit has instituted a policy change in regards to Heparin Sodium. I talked in an earlier post about the indications for Heparin...In my unit we mainly use heparin sodium in the IV fluid bags of central lines.
As of this evening all heparin was removed from our suremed (that pharmacy stocks) and from now on ALL heparin will be mixed in our fluids down in pharmacy to try to minimized any future errors of this magnitude. However, I have mixed feelings about the new policy. First, pharmacy stocks the suremed (let's remember that eventhough the nurse administered the wrong concentration, the pharmacy had the med stocked incorrectly) so by removing the nurse, we lose a "check" system. Now nurses will be administering it, not knowing if pharmacy made a mistake. We all mistakes and many people were involved in the error in Indianapolis, but is taking out one method of checks and balance a better idea?




Today's Quote:
"Don't be afraid to fail. Don't waste energy trying to cover up failure. Learn from your failures and go on to the next challenge. It's OK. If you're not failing, you're not growing."
H. Stanley Judd