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M.D. reports duplicate dose error; PSA drives essential change

August 2013

PSA Report it!

True Legacy story: A patient received a potentially harmful, duplicate dose of a medication. An anticoagulant was given in the ED, then again on the unit. The pharmacist reviewing the inpatient order couldn’t easily "see" in the EHR that the same med had been given prior to admission and so did not catch the duplicate order.

This event surfaced because a physician submitted a Patient Safety Alert (PSA).

As a result of the physician’s PSA, pharmacy screens were changed so that pharmacists can now readily see both pre- and post-admission med orders.

Each hospital has a process to regularly review and follow up on PSAs.

"Too much hassle"

Physicians are often reluctant to submit a PSA. Said one, "It’s too much hassle, I just want to tell somebody." But what if that physician hadn’t taken the 3–5 minutes to report the duplicate dose?

Back in the day, errors and "incidents" prompted blame and finger-pointing. The fewer reported incidents, the better. Today, patient safety comes first. In fact, "problems are golden," meaning they provide opportunities to catch errors, fix or improve issues, and identify trends.

To submit a PSA, use the Report It! link on the MyLegacy home page.

Submitting a PSA is essentially a statement of your concern for your patients’ safety. Next time you see an opportunity, please take a few minutes to share your concern.

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