Inside Duke Medicine
Living our values: Safety
posted September 13th, 2011
Duke HomeCare & Hospice therapist Bob Yane.
Therapist spoke up, ensured patient’s safety
When therapist Bob Yane visited a knee replacement patient at home for a routine progress review, he discovered and resolved a significant patient risk. Rather than passing the problem off to a nurse for resolution, Bob focused on ensuring patient safety.
During a routine check of prescriptions, Yane discovered that the patient was using a pre-dosed syringe containing twice the recommended dosage of an anti-clotting drug. “Given the patient’s condition, the patient could have bled to death with a dosage that high,” Yane said. “At a minimum, he was a risk for further complications.”
The dosage problems resulted when the patient’s community pharmacist attached a note to the syringe dosage advising the patient to use only half the dose in the syringe. But the patient never saw the note.
“At Duke, we talk constantly about the need to review medicines during in-home patient visits,” Yane said. “That was one of the first steps we took. We compared what the patient was taking with the physician prescription list.”
View the complete pdf of the Sept. 2011 Inside Duke Medicine or click through the articles online.