دورية أكاديمية
Can't find the antidote: A root cause analysis.
| العنوان: | Can't find the antidote: A root cause analysis. |
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| المؤلفون: | Abu Esba LC; King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.; King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia., Mardawi G; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia.; Pharmaceutical Care Services, King Abdulaziz Medical, Riyadh, Saudi Arabia., Al Deeb M; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia.; Department of Emergency Medicine, Medical Toxicology division, King Abdulaziz Medical City, Riyadh, Saudi Arabia.; College of medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia. |
| المصدر: | Frontiers in pharmacology [Front Pharmacol] 2022 Sep 06; Vol. 13, pp. 895841. Date of Electronic Publication: 2022 Sep 06 (Print Publication: 2022). |
| نوع المنشور: | Journal Article |
| اللغة: | English |
| بيانات الدورية: | Publisher: Frontiers Media] Country of Publication: Switzerland NLM ID: 101548923 Publication Model: eCollection Cited Medium: Print ISSN: 1663-9812 (Print) Linking ISSN: 16639812 NLM ISO Abbreviation: Front Pharmacol Subsets: PubMed not MEDLINE |
| أسماء مطبوعة: | Original Publication: [Lausanne : Frontiers Media] |
| مستخلص: | Background: In a series of cases that came to be recognized as a national methanol outbreak, an incident of delay in allocation and treatment with the antidote fomepizole is described with aim of sharing a learning experience. Method: A team of 16 members was formed to conduct a Root Cause Analysis (RCA), which included multiple individual interviews with the stakeholders and inspection visits to the area. Results: Root causes: The restocking process was unclear and inconsistent and specifically lacked a restocking policy for antidotes, inappropriate labeling and area design, and a sound-alike between fomepizole and omeprazole. Contributing factors included: unsuitable restocking practice and lack of training in using the pharmaceutical electronic inventory system. Corrective actions were recommended and implemented. Conclusion: Management of antidotes in large healthcare systems requires a team effort to ensure appropriate and timely availability in emergency poisoning cases. This RCA identified important areas for improvement that could be insightful to other institutions in preventing similar vulnerabilities and is unique in describing the details of system improvements that can have a large impact on patient safety. Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. (Copyright © 2022 Abu Esba, Mardawi and Al Deeb.) |
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| فهرسة مساهمة: | Keywords: antidotes; fomepizol; methanol; poisoning; stocking |
| تواريخ الأحداث: | Date Created: 20220923 Latest Revision: 20220924 |
| رمز التحديث: | 20240628 |
| مُعرف محوري في PubMed: | PMC9488554 |
| DOI: | 10.3389/fphar.2022.895841 |
| PMID: | 36147314 |
| قاعدة البيانات: | MEDLINE |
Full Text Finder | تدمد: | 1663-9812 |
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| DOI: | 10.3389/fphar.2022.895841 |