Targeted News Service
October 17, 2012
A Purdue University medication safety expert said it is important to look at the larger system surrounding medication use, as well as the facilities where drugs are made, to avoid tragedies such as the meningitis outbreak that has claimed 15 lives.
“No one condones making a bad product, but we also need to examine the quality assurance process of the larger medication-use system that doesn’t catch it,” said John B. Hertig, medication safety project manager for the Purdue College of Pharmacy’s Center for Medication Safety Advancement.
“It is a failure of the larger system and practices that allow a harmful product to make it through numerous hands and be administered to a patient. A systemwide view is the most effective in improving overall patient safety.”
The broader pharmaceutical system can be thought of as a stack of slices of Swiss cheese, Hertig said. Each step in the system, from manufacture to actual product use, has holes where a mistake could go undetected. It is only when the holes in each piece line up that a mistake can make it all the way through to a patient, he said.
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