Anybody has done a major clinical intervention recently?
Active Member
Anybody has done a major clinical intervention recently?
Moderator
Do you mean 'saved a life' ?
I remember young Drs being very chuffed when they considered that they had indeed saved someone's life.
johnep
Registered Pharmacist
done a fair few over the past week, wouldn't say saved a life but probably made sure we haven't sent someone into renal failure or under treated an infection
Active Member
No not necessarily 'saved a life'Originally Posted by johnep
Just some examples.
Moderator
Last time could have been an intervention but wasn't was the sodium phosphate affair.
johnep
Active Member
Care to elaborate?
Moderator
Trust you were referring to my post re sodium phosphate. The sln is used in many procedures. The case was a bronchoscopy.
The pharmacy usually supplied single strength, but owing to 'mcs', they ordered 10x which the ordering technician did not realise meant 10 x strength. Dr used straight out of bottle, pt died agonising death. Pharmacy took a share of the blame and I wondered on this forum if a criminal prosecution would follow. Could easily been an example of simple transposition error.
johnep
Registered Pharmacist
i'm assuming it was a series of errors which led to this happening....technician not realising the strength, not being checked by say a pharmacist, doctor not double checking the product before use....swiss cheese effect!!
similar to the case of the intrathecal vincristine...a day of error after error resulting in death
Member
An interesting one that you might not think of....When I worked in Geri I had a patient that kept being admitted with high INR. They would stabilize her and send her home - always on the same warfarin dose she had been on (dose confirmed with doctor and her daughter - 5mg od). I met her on her 3rd time on the ward when I was consulted to come up with an alternative anticoagulant strategy for her (she had Afib). I decided to do a med review, and had her daughter bring in all her medications for review. I make it a rule to always open rx bottles to visually check whats inside as patients often move pills into different bottles (particularly if the don't speak English - they will write a translation on one label and use the bottle over and over). Anyways - it turns out her bottle labeled enalapril 5mg bid actually contained warfarin 5mg tablets - I thought it was a nice example of how clinical problems are often simpler than you realize and can be solved by taking some time with the patient/caregiver. Docs had me doing admission med reviews with EVERYONE after that.
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