Before dismissing the above headline as melodramatic, please consider “How Medical Staffs Can Learn From the Mistakes of Others” published on HealthXPert.org. The article refers to the Joint Commission Journal on Quality and Patient Safety’s publication that exposed the 2006 death of a pregnant teen at a Wisconsin hospital after a nurse “intending to administer penicillin, instead hooked up a look-alike bag of anesthetic—meant to be delivered later by epidural route only—through [the nurse’s] IV.”
Looking to learn from hospital errors, the article points to “general recommendations that could be used in any hospital where medication mistakes are a danger because of look-alike packaging or a chaotic environment.” Those included the following two packaging recommendations:
• Use different shaped or sized containers to differentiate IV meds from epidurals.
• Apply warning labels to both sides of an epidural bag and over the access port used to spike the bag.
Given the pressure-packed nature of the emergency room or operating room, packaging must be designed to assist busy healthcare professionals. Kudos to HealthPack for soliciting the input of nurses in designing ER and OR packaging, and for making those results known to the packaging community.
