A new start, and purpose

I'm starting out again... After re-thinking the purpose for this blog, I've decided to rename it. The original name, Health Care Experience, seemed too broad and ambiguous. The new name, The Five Rights, is a common phrase in health care quality improvement circles. It has to do with medication safety - Right Drug, Right Patient, Right Dose, Right Time and Right Route. While this is far from all the aspects of the medication use process, it captures the essence of the issue and my passion.

Why medication safety? I've witnessed the problem first hand. Many years ago, I was a pharmacist at a large urban hospital in Seattle. We cared for children undergoing bone marrow transplant. One morning, I came into work, and the mood was very somber on the nursing unit I worked on. Usually friendly staff averted their eyes from my gaze... what was going on?? I found out quickly that there had been a re-admit during the night. A little girl, 8 years old had been given a mis-filled prescription by our outpatient pharmacy on her way home the day before. Rather than the mild antibiotic she was supposed to receive (doxycycline), she was dispensed a powerful tranquilizer (doxepin). After only a couple doses, her parents knew something was wrong and rushed her in.

Despite the fact I personally had nothing to do with the error, I took it deeply to heart. I felt terrible, responsible in some way. The rest of that day, I did everything in my power to help the family. I took the front end role as the face and heart of the pharmacy in their eyes. In the end, the parents were very understanding and the girl only had very mild and temporary symptoms. We dodged a bullet.

From then on, I realized what the possible impact of an error in pharmacy means. We do not come in to work in the morning thinking "I'm going to make a mistake today." Why do the systems fail us? What we now call casually a "LASA" error ("Look Alike Sound Alike") was allowed to proceed to patient harm. I can put an 8-year old girls face to it. In fact, there were few, if any "systems" in our pharmacy to handle such an event. Human error, inevitable, was not accommodated and mitigated in the technological systems people worked within.

So the focus of the blog will be medication safety. How technological systems can support it. How pharmacy clinical activities support it. Despite all our efforts, there will always be more to do. Because health care is ultimately a human system and will, by definition, be error prone. I've seen it. The cost is too high...

~charles