O C T O B E R 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
SAFETY
5 practical pearls
Other ways to prevent a mix-up:
•
Clearly label syringes.
Remind staff that all filled syringes in the OR
must be clearly labeled with their contents.
•
Audit drug stocks.
Periodically audit drug stocks in the OR to make
sure that methylene blue hasn't snuck back to where it doesn't
belong.
•
Follow a "hear-back" system.
When a nurse
hands the surgeon the drug, he should repeat
its name back to the nurse (Nurse: "This is
the VisionBlue." Doctor: "Okay, this is the
VisionBlue.").
•
Be aware.
This isn't the only blue-dye con-
fusion. Retinal surgeons sometimes use a dye
called MembraneBlue during vitrectomy sur-
gery to visualize membranes and the vitreous.
If accidently used during cataract surgery, it
could damage the cornea.
•
Educate your staff.
Discuss these 2 cases with
your staff. There's nothing like an employee hear-
ing about a case and thinking Wow, that could
happen here to make her follow proper proce-
dure. OSM
Mr. Truax
(
b trua x@pa tientsa fetysolutions.com
) is a
patient safety consultant (
pa tientsa fetysolu-
tions.com
) and a former clinical associate pro-
fessor of neurology at SUNY Buffalo (N.Y.) School
of Medicine.
www.cim-med.com
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