Therese Staublin, Pharm.D. of St. Francis Hospital and Health Centers writes: "We had a machine that was used to compound solutions for Continuous Renal Replacement Therapy. The machine has several buttons on it. One set of buttons is changed with every patient. The other set of buttons are never supposed to be changed. These buttons are used to program the specific gravity of the solution into the machine so that the machine can accurately measure the additive. Ideally, the manufacturer should provide a way for the person setting up the machine to lock the buttons after the initial setup. Without this safety feature, we had several incidents where a technician accidentally changed the wrong setting.

Our method for prevention was to apply self-stick prickly velcro pieces to the "bad buttons" to provide tactile feedback that the wrong button was being used. We did not have another event related to this issue, but this machine was replaced by different technology soon after we implemented this change.

As you can see from the machine, we had already tried putting reminders on the machine of what the numbers were supposed to be."


Mistake-proofing category: Mistake prevention
Setting function: Physical or perhaps information enhancement
Regulatory function: Sensory Alert
Source: Developed locally


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