Multilayers

One thing I have noticed about the errors I have made... distraction. I do not mean distraction with other team members or music, but the distraction within the order itself. Take for instance an order written for an IV fluid with no rate written from the ER. Immediately the info missing is the glaring distraction of the true issue: the MD wrote for incompatible fluids. It is easy for me to forget the multilayer dimension of errors. Overlook the error within the error. Those always seem to make me stop and think. Maybe errors come in pairs.

A pharmacist is like a detective trying to solve a case. May your cases always be easy and obvious!