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The Independent Double Check and the Risk of Human Error
A nurse on a telemetry floor had two orders to carry out. Forty milligrams of Lasix, to be given via IV. Two units of insulin lispro, given subcutaneously. At that hospital, every dose of insulin required a second nurse to co-sign, even subcutaneous doses. She scanned the patient. She scanned both vials. She drew up both medications. Then she tapped a colleague on the shoulder. The second nurse checked the patient. She checked the label […] The post The Independent Double Check and the Risk of Human Error by Mark Graban appeared first at Lean Blog by Mark Graban.
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