All of Us Fail to Match Our Dreams of Perfection

January 2019 - Vol. 16 No. 1 - Page #1

Acknowledging our own fallibility can be difficult, especially when it follows the application of extensive experience and expertise. Yet such acknowledgement is an important aspect of any well-run system, as humans are prone to error, no matter the circumstances. In some cases, such as when preparing and administering powerful medications, human error can lead to disastrous consequences, and in this month’s issue we explore ways in which IV push medications can be safely prepared and administered (click here to read the White Paper).

In other cases, such as a printing error in a professional publication, the consequences are less dire, but the message is the same: We all make mistakes, so it is important to employ systems to minimize the incidence of those mistakes moving forward. In this past December’s issue, we printed Kevin Hansen’s white paper incorrectly; an error passed through several layers of checks unnoticed. We take our responsibility for accuracy seriously at PP&P and are using this event to improve our own quality assurance program.

Kevin’s insightful white paper is also freely available to download at and we encourage you to read and absorb this valuable information. Further, Kevin’s webinar on the topic is available, along with all our other webinars, at

As we head into a new year, take the time to review those processes that would benefit from a quality overhaul and find ways to automate systems to mitigate human error as much as possible. Because none of us is perfect, improvement, as always, remains the goal.

All the best,

R. Mitchell Halvorsen

by Kevin Hansen, PharmD, MS, BCPS

  • Explore the impact of persistent, severe drug shortages, which have resulted in clinical practice changes at many hospitals across the nation
  • Review how clinicians have adopted alternative, and often riskier, compounding methods or routes of administration, including IV push
  • Ensure patients are protected by establishing safe IV push medication preparation and administration processes


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