Comments on: Behind the Libby Zion case http://www.kevinmd.com/blog/2006/11/behind-libby-zion-case.html Tue, 14 Feb 2012 17:18:00 +0000 hourly 1 By: L.J.Davis, PharmDhttp://www.kevinmd.com/blog/2006/11/behind-libby-zion-case.html#comment-69341 L.J.Davis, PharmD Tue, 05 Dec 2006 09:05:00 +0000 http://clients.emmense.com/kevinmd/2006/11/behind-the-libby-zion-case.html#comment-69341 Yes, this was the classic Demerol and Nardil MAOI interaction and the case single handedly started the medical errors movement in the 1990's. Since then a lot of progress had been made in bringing awareness to root cause analysis in assessing medication errors and focusing on faulty systems rather than pointing fingers at the people. Most of the time multiple systems problems can be traced to the root cause that allowed the error to occur. However, issues such has order clarification and double checks, order legibility, inappropriate use of abbreviations, lack of leading zeros on decimal points, hazardous drugs on nursing units (e.g. concentrated KCL injection, etc.), lack of standard protocols for narrow therapeutic index drugs (heparin, insulin, etc.) and many other systems problems still need to be addressed in many hospitals. Yes, this was the classic Demerol and Nardil MAOI interaction and the case single handedly started the medical errors movement in the 1990′s. Since then a lot of progress had been made in bringing awareness to root cause analysis in assessing medication errors and focusing on faulty systems rather than pointing fingers at the people. Most of the time multiple systems problems can be traced to the root cause that allowed the error to occur. However, issues such has order clarification and double checks, order legibility, inappropriate use of abbreviations, lack of leading zeros on decimal points, hazardous drugs on nursing units (e.g. concentrated KCL injection, etc.), lack of standard protocols for narrow therapeutic index drugs (heparin, insulin, etc.) and many other systems problems still need to be addressed in many hospitals.

]]> By: Gasmanhttp://www.kevinmd.com/blog/2006/11/behind-libby-zion-case.html#comment-69127 Gasman Tue, 28 Nov 2006 12:46:00 +0000 http://clients.emmense.com/kevinmd/2006/11/behind-the-libby-zion-case.html#comment-69127 Phenelzine, and the other MAO inhibitors, are not used much any more. I wonder though whether the system is any better equiped to avoid this error today than it was two decades ago. An alert well rested physician might not recognize the drug as belonging to the MAO class; further there are drug interactions too numerous to list here, with meperidine being among the still lesser known. <br/>The full hazard of these MAO drugs is that they are persistent in effect, such that caution may be needed even weeks after they are discontinued. <br/><br/>Most computerized hospital pharmacy systems still do not have the benefit of knowing the patient's prescription drug history prior to an admission, so carefully planned drug-drug interaction warnings would be of no use. <br/><br/>Given the range of situations your depressed patient might find themselves, the only safe way to prescribe a MAOi drug would be to have that patient wear a MedicAlert bracelet. At least then hospital staff would have a fighting chance to learn the patient was on such a drug. Phenelzine, and the other MAO inhibitors, are not used much any more. I wonder though whether the system is any better equiped to avoid this error today than it was two decades ago. An alert well rested physician might not recognize the drug as belonging to the MAO class; further there are drug interactions too numerous to list here, with meperidine being among the still lesser known.
The full hazard of these MAO drugs is that they are persistent in effect, such that caution may be needed even weeks after they are discontinued.

Most computerized hospital pharmacy systems still do not have the benefit of knowing the patient’s prescription drug history prior to an admission, so carefully planned drug-drug interaction warnings would be of no use.

Given the range of situations your depressed patient might find themselves, the only safe way to prescribe a MAOi drug would be to have that patient wear a MedicAlert bracelet. At least then hospital staff would have a fighting chance to learn the patient was on such a drug.

]]> By: cdclledhttp://www.kevinmd.com/blog/2006/11/behind-libby-zion-case.html#comment-69123 cdclled Tue, 28 Nov 2006 06:12:00 +0000 http://clients.emmense.com/kevinmd/2006/11/behind-the-libby-zion-case.html#comment-69123 I hear physicians complain all the time (mainly surgeons) that 80 hour restrictions have a negative effect on patient care because there is less "continuity of care." This may be true. I'm sure there would be even greater continuity of care if all doctors worked 36 hour shifts all the time, but they don't. Why? because it's not practical in today's work environment. You have to draw the line somewhere. This is not the 1950s, we live in a sue-happy society that is constantly looking for someone to blame. Let the interns get some sleep I hear physicians complain all the time (mainly surgeons) that 80 hour restrictions have a negative effect on patient care because there is less “continuity of care.” This may be true. I’m sure there would be even greater continuity of care if all doctors worked 36 hour shifts all the time, but they don’t. Why? because it’s not practical in today’s work environment. You have to draw the line somewhere. This is not the 1950s, we live in a sue-happy society that is constantly looking for someone to blame. Let the interns get some sleep

]]> By: Mariahttp://www.kevinmd.com/blog/2006/11/behind-libby-zion-case.html#comment-69119 Maria Tue, 28 Nov 2006 04:30:00 +0000 http://clients.emmense.com/kevinmd/2006/11/behind-the-libby-zion-case.html#comment-69119 Ah, but your experience, back when giants roamed the hospitals and interns had the boundless energy of ten thousand oxen, is what made and currently makes you STRONG STRONG STRONG. ;) Ah, but your experience, back when giants roamed the hospitals and interns had the boundless energy of ten thousand oxen, is what made and currently makes you STRONG STRONG STRONG. ;)

]]>