October 30, 2006 |

Monday Accident & Lessons Learned: More Questions on Heparin Mix-Up

Continued from previous blog note


Baby’s die and people ask: “How different do two bottles need to be to prevent a mix-up?”

Should the nurses have noticed the difference above when they took bottles out of a cabinet that was supposed to have the right bottles in it (but the pharmacy had accidentally stocked the wrong ones)?

In one article by AP, there was following quote from one of the one of the mothers:

Thursday Dawn’s mother, Heather Jeffers, said she blamed the nurses at the Indianapolis hospital for the overdose that led to her daughter’s death five days after she was born.

I can see how someone who just lost their newborn would blame those who injected the wrong drug.

But blame won’t prevent medical errors.

Blame never stops mistakes that are embedded in the system.

Blame is not a root cause.

I know what my friend John Grout would see – an opportunity for mistake proofing to help nurses avoid this problem.

Others say that “The 5 Rights” is the answer. (I’ve heard “If only they would have used the 5-Rights!”)

Still others claim that bar-coding would prevent these issues.

Why can’t we find the right answer and stop these tragic deaths?

If you work in the healthcare industry and would like to learn more ways to stop medical errors, there is a conference that I think you should attend:

The TapRooT® Summit

Dr. John Lighter has helped organize a special track for those interested in improving healthcare quality and stopping medical errors. For a complete schedule, click on the Medical Error Reduction button at this link:


In addition to the targeted breakout sessions focussed on improving healthcare and stopping mistakes, you will also be able to hear and meet several outstanding keynote speakers:

John Nance – Pilot, Author, ABC News Aviation Safety Consultant, and Healthcare Safety Speaker

Performance Lessons from the Cockpit to the Surgery Suite

Josh Davis – 5 Times Olympic Medalist

Olympic Success Lessons Learned

Judge Andrew Napolitano – NJ Supreme Court Justice and Fox News Consultant

Accident Lessons from the Courtroom

Beverly Chiodo – Award Winning College Professor

Character First!

Richard Hawk – Safety Speaker and Consultant

Creating a Vibrant Safety Culture

The Summit will be held in San Antonio, Texas, on April 25-28, 2007.

For more Summit information see:


To see a movie of what previous Summit attendees have to say about their experience see:


To download a Summit Brochure,
click here.

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