Day 2: The day started off with Mark Collins showing us a video about drug safety. It was an eye opener as I didn’t know how many patients die because of medication errors during their stay in the hospital. Even the best pharmacist, physician or a nurse can make a error given the right circumstances. I was moved by the grief experienced by families of the patient and feeling of guilt a health care professional has to overcome. We learnt that on average only about 10% of the errors are reported. Therefore, we need to get better at reporting errors as this would help us in improving the system and preventing these errors from occurring. We should not blame the person, but should strive towards fixing the system.
The overall message of the session was to become an active participant, know our ROPs () and take action. Dr. Collins shared an example of fentanyl overdose at a hospital in BC where the pharmacist followed the guidelines listed in the product monograph due to unfamiliarity with the dosing guidelines used by the hospital (where the recommended dose was much lower). This resulted in respiratory depression in the patient and action was taken to notify the manufacturer and change their recommended dose. I also learnt that constraints and restricting the concentration and amount of medication on the ward is the most effective strategy to prevent medication errors versus educating the staff.
Dr. Collins ended the session with a great message, “You don’t know what you don’t know, you have to experience it. Learn from others, check in with others, let them guide you.
High alert drugs: Check it 3 times. Don’t give in to peer pressure, take your time. Take individual responsibility.
Dr. Virani’s part: We learnt how fraser health is organized as an organization. We also gained some insight into how much money goes into running the pharmacy department.
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