Can’t find the antidote: A root cause analysis
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 (...
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| Format: | Article |
| Language: | English |
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Frontiers Media S.A.
2022-09-01
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| Series: | Frontiers in Pharmacology |
| Subjects: | |
| Online Access: | https://www.frontiersin.org/articles/10.3389/fphar.2022.895841/full |
| _version_ | 1828420492607881216 |
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| author | Laila Carolina Abu Esba Laila Carolina Abu Esba Laila Carolina Abu Esba Ghada Mardawi Ghada Mardawi Mohammad Al Deeb Mohammad Al Deeb Mohammad Al Deeb |
| author_facet | Laila Carolina Abu Esba Laila Carolina Abu Esba Laila Carolina Abu Esba Ghada Mardawi Ghada Mardawi Mohammad Al Deeb Mohammad Al Deeb Mohammad Al Deeb |
| author_sort | Laila Carolina Abu Esba |
| collection | DOAJ |
| description | 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. |
| first_indexed | 2024-12-10T15:13:13Z |
| format | Article |
| id | doaj.art-37b9c3080ab343e7820a7e540ccd6c50 |
| institution | Directory Open Access Journal |
| issn | 1663-9812 |
| language | English |
| last_indexed | 2024-12-10T15:13:13Z |
| publishDate | 2022-09-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Pharmacology |
| spelling | doaj.art-37b9c3080ab343e7820a7e540ccd6c502022-12-22T01:43:52ZengFrontiers Media S.A.Frontiers in Pharmacology1663-98122022-09-011310.3389/fphar.2022.895841895841Can’t find the antidote: A root cause analysisLaila Carolina Abu Esba0Laila Carolina Abu Esba1Laila Carolina Abu Esba2Ghada Mardawi3Ghada Mardawi4Mohammad Al Deeb5Mohammad Al Deeb6Mohammad Al Deeb7King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi ArabiaKing Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaKing Abdullah International Medical Research Centre, Riyadh, Saudi ArabiaKing Abdullah International Medical Research Centre, Riyadh, Saudi ArabiaPharmaceutical Care Services, King Abdulaziz Medical, Riyadh, Saudi ArabiaKing Abdullah International Medical Research Centre, Riyadh, Saudi ArabiaDepartment of Emergency Medicine, Medical Toxicology division, King Abdulaziz Medical City, Riyadh, Saudi ArabiaCollege of medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre, Riyadh, Saudi ArabiaBackground: 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.https://www.frontiersin.org/articles/10.3389/fphar.2022.895841/fullantidotesstockingpoisoningmethanolfomepizol |
| spellingShingle | Laila Carolina Abu Esba Laila Carolina Abu Esba Laila Carolina Abu Esba Ghada Mardawi Ghada Mardawi Mohammad Al Deeb Mohammad Al Deeb Mohammad Al Deeb Can’t find the antidote: A root cause analysis Frontiers in Pharmacology antidotes stocking poisoning methanol fomepizol |
| title | Can’t find the antidote: A root cause analysis |
| title_full | Can’t find the antidote: A root cause analysis |
| title_fullStr | Can’t find the antidote: A root cause analysis |
| title_full_unstemmed | Can’t find the antidote: A root cause analysis |
| title_short | Can’t find the antidote: A root cause analysis |
| title_sort | can t find the antidote a root cause analysis |
| topic | antidotes stocking poisoning methanol fomepizol |
| url | https://www.frontiersin.org/articles/10.3389/fphar.2022.895841/full |
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