Earlier this week my son had surgery to remove his tonsils and adenoids. We were able to take him home the next night and he has been concentrating on ice cream, popsicles, and episodes of Dinosaur Train on Netflix ($NFLX).
This week my focus turned to pain management. Not much is worse to me than a kid in pain. That is especially true when the kid is my own. While juggling all of these different drugs and doses comes second nature to my CRNA turned stay at home mom, it does not to me.
The last two nights we have been getting up every two hours to administer one of the three different pain meds he needs. Every time it is a different drug than the last time and each has a different dose that we need to give. The more tired we are the more careful we are in documenting who gave which drug when it is our turn to get up.
Back when I started my job as a medical simulation coordinator, one of the projects I worked on was creating a training exercise to introduce the topic of drug errors to anesthesia residents. We modeled our case after one published in the new (at the time) Agency for Healthcare Research and Quality (AHRQ) Web M&M database.(1) For this case, labeling of a drug (top of container) was similar to another drug placed beside it in a drug cart. In our case we have the error occur while care is being given by a provider while handing off the case to another provider.(2)
Drug errors can occur for any number of reasons. Drug concentration changes due to shortages seem to be happening more and more frequently. A decimal point in the wrong place can easily lead to injury from either an over or under dosing of the patient. Anesthesia care teams often include more than one person at the beginning and end of the case when the likelihood of needing more hands to help is greatest. In many drug errors it is this second person that is double checking things that will locate and bring the mistake to the attention of the team.
Last week I found that I had made an error in setting up our DittoTrade settings. When we were given the green light by Anne-Marie, I accidentally set the percentage of our total account to be used for each trade as 0.15 instead of 0.05. We found the error when I was confirming the settings for Anne-Marie. In this case it was her attention to detail that saved us from continuing with a potentially costly mistake.
Attention to details, consistent execution, and ability to know when need to be more careful are all qualities needed in medicine and trading. For me, I now have one more thing to confirm on order sheets.
Now, back to planning ways to get my son to drink more water tomorrow. Has anyone else played “aqua pong” with their toddler?
If you have not been following along with this sustainability experiment, you can catch up here.
1. Barach, Paul. Unexplained Apnea under Anesthesia. Febuary 2003. Agency for Healthcare Research and Quality.
2. Taekman Jeff M, Hobbs Eugene, Wright Melanie C. Intraoperative apnea: medication error with disclosure (simulation case scenario). Simul Healthc. 2007 Spring;2(1):39-42. doi: 10.1097/SIH.0b013e3180317c33.
Gene Hobbs is a technical diver and founding board member of the non-profit Rubicon Foundation. Hobbs has served as medical officer for the Woodville Karst Plain Project since 2004 and was named the 2010 Divers Alert Network/ Rolex Diver of the year. Hobbs is the medical simulation coordinator for a simulation and patient safety laboratory at a major university medical center.