Klinisches Risikomanagement

Abstract

Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).

Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system

“…Various factors contribute to the LASA incident, and accounts for 7-20% of all medication errors [1-5]: illegible handwritingoral and vague prescription (“half an ampule”)incomplete knowledge of name of medication and substancenewly released drugs in ever shorter periods of timesimilar packaging and labelingdismissing barcode technology at point of caresimilar clinical use of drugssimilar dosage and concentrationdiverging concentration on similarly looking packagingdisplaying concentration in percent instead of numerical unitsdismissing the use of capital letters (ie. PENTObarbital versus PHENObarbital)…”