What really burns

Mentioning that I was the recipient of a hot coffee burn at the drive-thru where I am a "regular" is embarrassing. Following the widely publicized case in the mid 1990's, the topic of "hot coffee burns" has been a polarizing topic. I try to stay away from issues like these, being more of a lover than a fighter in the war about what--from an evidenced-based standpoint--actually makes people safer.

But since the coffee actually fell into my lap on Saturday morning, I'll take it as a sign that I'm supposed to say something about the issue of human error and organizational response as it relates to the potential for hot liquid to spill on people who choose to purchase these products in a drive-thru.

I noticed that the lid to the cup on my coffee was slightly askew when I removed it from the drive-thru shelf where the server had placed it. I thought I could reseat it myself since the visible defect was only a 1/2" rise in what appeared to be an otherwise good seal. Unfortunately, what I would represent as gentle pressure downward on a paper cup not supported by anything except my left hand caused the cup to change shape. The lid popped off and nearly half of my large brewed coffee, with cream, hit my right thigh. It felt really bad for a few moments, the kind of bad that makes the back of your throat ache as the acute pain subsides.

The server on duty on Saturday frequently prepares my morning coffee, and the lid has always been placed correctly in the past. As I struggled to get myself back together and finish the transaction, she passed me napkins and gave me a new cup of coffee, appearing somewhat distraught. I'm thinking this is pure human error. A human will not seat a lid correctly 100% of the time. A customer may not know that the obvious corrective action of reseating a small defect will cause the cup to go askew and the coffee to spill. So I'm thinking it would be helpful for customers to know that it's safer to let the server fix a poorly seated lid than mess with it in the car. Maybe a sign in the drive-thru window saying something like, "If you notice the lid on a hot beverage is crooked, please let us fix it for you." I live in an area where a lot of people speak Spanish. So maybe the sign should be in both English and Spanish.

Since the server is a pleasant young woman and she looks kind of worried, I say to her, "I'm not interested in suing over a hot coffee spill here. But I am interested in making sure this doesn't happen to someone else." That's when she replied, "Oh, well it happens all the time. You should have seen the last lady- it was an extra hot cup of tea. We've been having trouble with these lids for awhile."

"Have you shared that with your manager?" I ask. "Oh yes," she replied. "They know all about it."

On Sunday, I return for my morning coffee. A different server is on duty. I mention the Saturday spill to her as I go through the drive-thru. I'm wondering if the cup problem is as widespread as Saturday's server had implied or if she may have felt more individually culpable than I had intended. She confirms the cups have not been performing well and that "the company" is trying to get better ones.

The red spot faded in a few hours, I have no compelling reason to revisit this issue. Except I know that by reporting a problem, reasonable people can take steps to prevent the problem from reoccurring. Customers can try to be more careful. You can hang a sign to point out risky conditions that can't be minimized in other ways. But those are low level risk-reduction strategies. Here's a more effective way to prevent burns: Cups that hold hot liquids should have lids that fit. They should be able to be manipulated into position by average workers and passed through the drive-thru window with a very low failure rate, if a business chooses to sell hot liquids in this fashion.

Sunday's cup was defect-free. And today's cup is fueling this post.

I'm just trying to help prevent someone else from getting burned.

Nuts!

Peter Pronovost may think we're nuts. Actually, he said doctors and nurses work in a system that's nuts. But, I'll toss off the virtual nurse's cap this morning, and offer the same advice I'd give to my kids: Nutty is as nutty does.

Pronovost, a well-respected patient safety advocate and practicing clinician, appeared in a Wall Street Journal blog post a few weeks ago, sharing his views about safety gains that could arise from hospital-industry-regulatory collaboration modeled on aviation partnerships. Advocating for measures that transcend what professionals closest to the secretions can pull out of their, well, shall we say, personal supply cabinets, Pronovost pointed out that clinicians who work in hospitals need better and more effective tools to prevent mishaps.

If an infusion meant to be delivered to the epidural space can kill a person if it's inadvertently infused intravenously (as has tragically occurred many times in the past), safest practice would be to make epidural tubing incompatible with the cousin ports populating the patient's nearby IV tubing. An engineered device constraint is far more likely to prevent patient harm than reminding clinicians who manipulate the lines to "be more careful" and placing labels on tubes and lines. Especially when the therapeutic care environment looks like this:

photo used with permission

Personal diligence and adjuvant labeling shouldn't be abandoned, but a constraint like incompatible tubing is a far more effective way to derail a significant error that has been set in motion.

If you've been following Flo's posts for the real-time patient safety lessons she offers, it's worth reviewing the medication use process, recalling that the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient.

Slide based on modeling described by James Reason

Tubing misconnections are errors that originate downstream, in the administration node, meaning there are limited opportunities to uncover them and prevent harm before they reach a patient. Engineered incompatibilities between epidural and intravenous line ports and connectors are powerful constraints, one of the few reliable ways to catch wrong-route errors arising from a clinician's slip, trip, or lapse at the point of medication administration.

When cross-functional stakeholders join forces in healthcare, as they have in aviation, your patients may be as safe while giving birth in the U.S. as they are while flying commercial.

This is not what I envisioned when I became an intrapartum nurse some years ago, but apparently what I should have been saying all along is, "I'm the SafetyNurse, fly me!" (My husband says I've been cleared for take-off, but he may be saying something unrelated to this topic. In any event, I hope you'll travel safely!)

The average Walmart shopper understands risk reduction!

A few weeks ago, a pediatric nurse shared an intervention that lessened the likelihood of an IV medication error. Her story celebrated nursing advocacy, the ability of professionals on the front line to recognize risk, intervene proactively, and make things safer for patients.

Last week, I went back to this pediatric infusion case, reviewing what a system analysis of the medication use process and seminal medication safety research tell us about risk. The take-away lesson? Errors that originate upstream are more likely to be discovered and corrected before the error reaches a patient while errors that originate close to the point of administration are less likely to be detected.


Here's another image prepared using the same seminal medication error data, illustrating more take-away lessons: errors that originate downstream are not only more likely to reach a patient, they are more likely to cause harm when they do.



Source: Leape L; Bates D; Cullen D; Cooper J; Demonaco H; Gallivan T; et al.Systems analysis of adverse drug events. ADE Prevention Study Group JAMA. 1995;274(1):35-43.

Now, let's look at the details provided in the original post:

• the patient was 3 years old
• the care setting was one that routinely cared for pediatric patients
• the patient was receiving an IV medication
• the medication infusing was not commonly used
• the professional staff were not using a drug administration protocol familiar to them
• no written guidelines for how to prepare the infusion or administer this particular drug were available
• the medication infusion required titration (the dosing unit provided in the post: mg/kg/hr)

On-duty personnel at the end of the night shift were observed struggling to perform the calculations needed to titrate the prescribed dose (0.84 mg/kg/hr) while adjusting doses in mL/hr increments. Calculations of this nature are possible, but they are complex, error-prone, and more likely to be botched when performed by fatigued workers. It's also high-stakes work that's occurring while the infusion is attached to the patient, about as far downstream as you can go in the medication use process.

A routine medication, dose, and rate check performed by the oncoming nursing team revealed that the medication was being administered as prescribed. A change in the medication concentration advocated by the oncoming nurse simplified the rate and dose relationship, removing the need to perform complex mathematical calculation to titrate the dose at the bedside. Risk was reduced.

This represents very good work by the team at the bedside, who used tools available to them to reduce error potential. Other positive call-outs include: the setting was one that routinely cared for pediatrics; independent double-checks are part of the clinical culture; staffing was such that a seasoned nurse had time to consider risk-reduction strategies and advocate for change; and the professional culture is described as one that values inter-disciplinary communication and respect.

When I first read this case, though, I was struck by the image of front line clinicians trying to avert disaster, much the same as an airline crew in flight might have to work to solve an emergent in-flight problem. Where was the ground crew, I wondered? How much of the time-robbing, disaster-avoidance described by the nurse at the bedside could have been averted by better "pre-flight" processes? Do solutions implemented by bedside clinicians, using a relatively closed set of variables, yield the strongest possible risk reduction, or does the process become just a little "less risky"?

Administering intravenous medications to a pediatric patient is a high-stakes activity, but it is not a rare one, at least in this setting. (Spoiler alert: You're not going to find a link to a mega-document with a full-blown Failure Modes and Effects Analysis about pediatric medication infusions!)

Instead, let me leave you with a few high-level risk reduction strategies to consider, many that you'll recognize if you practice in a setting where The Joint Commission (TJC) standards frame clinical care. I'm not claiming expertise in TJC standards interpretation nor am I offering advice about what any particular organization should do to minimize risks associated with pediatric medication administration. (You can, however, find some here.)

But I like to think that anything that can be understood by the average Walmart shopper is worth sharing, so I'm closing with a few observations about how this Walmart shopper sees risk-reduction.

Risk-reducing activities are often reflected in TJC standards, and the "science behind the compliance" is often based on failure mode and effects analysis. These are things the "ground crew" should be thinking about to ensure the people on the flight deck have what they need to get the job done:

• Establish standard concentrations for all IV medications (even the ones not often used). When IV medications are added to an organization’s formulary, they are subject to specific processes (usually under the auspices of a Pharmacy & Therapeutics Committee). These should ensure that standard drug concentrations are defined and incorporated into the tools used by professionals to prescribe, dispense, and administer the medication.


• IV drug infusions are ideally prepared in a pharmacy. When operational barriers to pharmacy preparation occur--in care settings without 24 hour pharmacy or in regions where unit-based drug preparation is the standard of care--staff members who admix medication should have access to guidelines specifying the standard concentration along with detailed admixing instructions. Clinicians who administer infusions should have easy-access to sanctioned dose conversion charts.


• “Smart” infusion pumps, with drug libraries programmed to reflect standard concentrations, make weight-based dosing even more simple. Dose-checking programming modes remove the need for manual calculations while immediately alerting clinicians--just prior to administration, the last possible discovery point--if an inappropriate dose has been inadvertently programmed.

There are other high-end strategies for reducing pediatric drug errors, some in development and some already being used in clinical settings. I encourage you to share yours. As for me, it's Friday, and I'm off to Walmart!

Risk points across the medication use system

Recently, Nurse Ausmed shared a great post about an intervention that lessened the likelihood of an IV medication error occuring in a pediatric patient. Her take-away lesson was "simplify, simplify," a core principle in safe medication practices.

Earlier this week, I wrote that Nurse Ausmed's online case study would lend itself to a basic excercise in identifying the latent (or upstream) conditions that often lead to error on the front line. Links to ideas about modeling human error (developed by James Reason) and some online pediatric medication safety resources were provided.

Here are my initial thoughts:

To answer the question, "Could the error-prone condition be identified and the potential for patient harm lessened before it reached the front line?" start by considering what the medication use system looks like:

The roles and responsibilities of professionals ("who does what, when, and how") may vary according to practice setting and applicable professional standards of care. Irrespective of setting, however, prescribing, transcribing, dispensing, administering, and monitoring are the units, or nodes, that make up the medication use system.

It's important to pause for a moment and take this in. As individuals, we typically focus on the portion of the system where our own professional duties lie, rather the system as a whole, making it difficult to see upstream opportunities.

Now consider the problem of errors in the medication use system:

Errors may originate at any point in the process. In the slide below, the red arrow illustrates how an error that began in the prescribing phase is not picked up, moving through all downstream defenses to reach the patient.

Seminal medication safety research shows the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient. This is why processes like independent double checks and automated clinical decision support are valuable: they make errors and error-prone conditions visible before they reach the patient.

Unfortunately, errors that originate in the administration phase are highly unlikely to be picked up before they reach the patient. This is why processes at the point of administration should be as simple, standard, accurate, and dependable as feasible. (I think of clinicians who administer medications and the processes they use as I would a flight crew: it's probably not a good idea to expect problems to be solved at 35,000 feet that could have reasonably been resolved on the ground or to use patchy processes to accomplish high-stakes, in-flight tasks.)

Later next week, I'll come back to this topic, using clinical information Nurse Ausmed shared to help identify strategies for preventing IV medication errors in peds that are on the high end of the risk reduction hierarchy. I'd hope you'll share the risk-reduction strategies you use when you care for pediatric patients.

Stay safe and come back soon! I've been thinking about something I heard Paula Poundstone say last week, and the next time you check in, you need to be ready to laugh!

Get ready to cancel the launch!

In Lessons from a Sunken Ship, I recounted the story of a 1628 shipwreck that occurred in the aftermath of a failed stability test, a test result known to at least 30 shipbuilders (who nearly put the Vasa underwater during a preliminary test of seaworthiness) and the ranking military leader who observed the aborted test. Signing off on the launch, the ranking officer lamented the absence of the King, apparently the only person with authority to cancel the launch.

This story lends itself to talking about the dangers of rigid hierarchies, and I'll probably return to it at some point, rigid hierarchies having sunk more than a few ships in healthcare. But the Vasa also illustrates principles about the hierarchy of error and harm prevention:

1. Eliminate or prevent mistakes. A better design would have prevented the Vasa from going down.

2. Make mistakes that have been set in motion visible. The ship did not perform as expected when subjected to simulated sea-like conditions. Not launching a ship with dubious stability would have prevented the Vasa from going down.

3. Mitigating the hazard should a mistake occur. Lifeboats prevented some people on the sinking ship from going down.

4. Education/re-education about how to manage known hazards. Swimming lessons might have helped some people save themselves.

Healthcare has been criticized for the tendency to bottom feed when it comes to risk reduction, meaning that we tend to rely on risk-reduction strategies low on the hierarchy. This doesn't mean that, as individuals, healthcare professionals don't care about risk or don't want things to turn out well. It simply means that we're more likely to select and implement interventions like "review policy" with individuals who make errors than to examine the underlying factors that allowed frontline workers to err. We spend a lot of energy attempting to teach front line clinicians how to save themselves.

So if we got out of the lifeboats and headed north on the risk-reduction hierarchy, how far could we go and what would the consequences be?

Health and healing are complex, and it's fair to say that we're sailing more than a few badly designed ships. 1 in 7 Americas lack healthcare insurance. Healthcare disparities are rampant. Patients are older, sicker, and rounder than they used to be. Our system does not incentivize prevention. A better design would avert many crises. But redesign of healthcare--something that appears to be emerging as a national priority--is outside the locus of control of individual clinicians, irrespective of how often or how nobly we face the consequences of the current bad design.

So how can front line clinicians prevent a poorly designed vessel from sinking? One answer is: embrace processes and procedures that make mistakes set in motion visible. Be able to identify emerging practice changes as the higher-level risk-reduction strategies they are. Get ready to cancel the launch!

A bar-code scan reveals a mismatch between ordered medications and a similarly packaged one in the patient’s drawer: you’ve cancelled a launch. A pre-procedure time-out reveals a site-of-surgery discrepancy: you’ve cancelled a launch. Reading back and verifying a telephone order (insulin 50, five-zero, units sub-cutaneously now) reveals the prescriber on the crackly line said one-five (15), not 50 units of insulin: you’ve cancelled a launch.

Cancelling a launch is not as good as preventing mistakes from occurring. But this approach trumps lifeboats and swimming lessons. Right now, healthcare is adopting, occasionally adapting, risk-reduction strategies from other industries, industries more reliable than ours.

The best risk-reduction strategies, in my opinion, are yet to come. As healthcare workers--bright, caring, and competent individuals—come to understand the principles that drive reliable performance, participate in developing highly-reliable processes, demand these be vigorously applied, and eventually come-of-age in an environment where reliability is the norm, it will no longer be necessary to report preventable adverse health events as aggregate data!

See you there!

Sign, sign, everywhere a sign.

I keep getting, ummm, signs.

A sign that arrived in an e-mailed joke a few weeks back inspired me to write about high reliability.

Then Bill ("Here's Your Sign") Engvall gave me one, causing me to make mention of the fact that all risk-reduction strategies are not created equal.

And just a few minutes ago, I found this one while checking out the Facebook page of Shelby Caldwell, a talented young photographer:

used with permission

I'm not certain if the abundance of signs means the people at this grocery store really, really, really don't want you to fall (in which case a bag boy with a shovel and some salt might confer better protection) or if they want to warn you that you're about to fall irrespective of which space you park in or which cart queue you pull from.

(It may be helpful to know that where I live snow, especially spring snow, often melts before a "snow removal crew"--ummm, bag boy and shovel--can be mobilized.)

Since I can't say it better than the 5 Man Electrical Band did many years ago, I'll leave you with this:

"Sign, sign, everywhere a sign
Blockin' out the scenery,
breakin' my mind
Do this, don't do that, can't you read the sign"

"Here's Your Sign" is not a High-End Risk-Reduction Strategy. Go Figure.

I live in the southern part of the U.S., and, like most of my friends, I like Bill Engvall, one of the funny men on the Blue Collar Comedy tour. Larry the Cable Guy, not so much, but I really think Bill Engvall is funny. If you don't know who he is, here's one of Engvall's jokes (and a link that takes you to the lyrical version of "Here's Your Sign"):

A couple of months ago I went fishing with a buddy of mine, and as we pulled his boat into the dock, I lifted up this big 'ole stringer of bass.

This idiot on the dock goes, "Hey, y'all catch all them fish?"

"Nope. Talked 'em into giving up."

I like Bill Engvall’s take on the human condition. It helps me make it through the Walmart. But when I go to work, I try to leave Bill behind. Here’s why:

In Chipping Away at Risk, I talked about how professional standards in other industries call for the use of the highest feasible strategies to manage predictable risks, and noted that similar thought processes are not yet considered "the norm" in the healthcare culture. In healthcare, it’s easy to draw from our duty-oriented traditions, falling back on what an “A player” wants to do on a good day rather than what a “B player” produces on an average day. (We will not discuss "C players" today.) But Human Factors research tells us that different, more reliable processes are needed to manage predictable risks that arise when people, processes, and equipment converge: "Hey, y'all catch all them fish?"

So here’s a user-friendly list of risk reduction strategies, one that’s widely used by the safety analysts at the Institute for Safe Medication Practices. The strongest error-reduction strategies are listed first, with the less effective options lower on the list:

• Fail-safes & Constraints
• Forcing functions
• Automation & Computerization
• Standardization
• Redundancies
• Reminders & Checklists
• Rules & Policies
• Education & Information
• Suggestions to be more careful or vigilant

And three examples showing how these principles look “on the job”:

1. A patient care unit where the primary fall-prevention intervention involves nursing personnel “keeping a close eye on patients at-risk to fall ” is using a less reliable fall-reduction plan than a unit where nursing vigilance is augmented by standard measures (such as the opportunity to use the bathroom every two hours). This can be predicted because scheduled opportunities to use the bathroom standardizes an intervention while “keep a close eye on them” relies on personal vigilance, a much weaker risk-reduction strategy.
2. A neonatal unit that has a policy stating only 10 units/mL heparin will be stocked in the unit’s automated dispensing cabinet (ADC) has a less reliable risk-reduction plan in place than a neonatal unit where heparin products undergo bar-code scanning prior to delivery to the unit and prior to being prepared for a given patient. Bar-coding is an automated risk-reduction strategy with reliability that trumps both policy statements and the accuracy of humans when “reading the label.”
3. Port-free epidural tubing, especially those with distinguishing colors and features, makes patients safer than using standard IV tubing because the absence of a port is a constraint that can prevent inadvertent administration of parenteral drugs to the patient’s CNS, a tragic occurence that regularly happens when well-educated clinicians become distracted.

I hope the rank order of risk reduction strategies and the clinical examples give you something useful to consider about mitigating on-the-job risks and how to respond when an error occurs.

Stay safe, find some time to fish, and come back soon!

Chipping Away at Risk

I had an unusual introduction to Human Factors (HF) engineering when I served on a jury that heard a chipper-shredder mishap in the mid '90s. I'll forgo the tragic details that gave rise to a suit against the manufacturer, and leave you with just the take-away lesson: if a machine's outer casing is shielding a series of free-swinging blades seated on a spinning Ferris wheel-like device, the likelihood of your hand being sucked in from below (at the small, innocuously-appearing exit shoot) is as great as it is from above (at the larger entry hopper where you toss yard debris). This information becomes even more relevant should be you be tempted to free--even from a distance well away from the exit shoot--a thorny vine caught around the spinning Ferris wheel device.

During the course of the two week trial, HF expert witnesses gave our jury a soup-to-nuts education about chipper-shredders, attempting to get us up-to-speed about design principles, mechanical features, and professional standards manufacturers must conform to.

It did not come as a surprise to HF expert witnesses--neither those testifying for the plaintiff nor those testifying for the defense--that human beings and chipper-shredders had a high potential for yielding tragic outcomes. In fact, a manufacturer's ability to bring a high-hazard product to market, and keep it there, hinges on whether it can be made safe enough to protect people from the predictable mistakes they are likely to make while using it.

While I found the mechanical aspects of chipper-shredder design interesting (even using the information when purchasing a chipper-shredder of my own a few weeks later), I experienced a profound "ah-ha" moment when I realized how differently HF experts evaluated risk and selected risk-reduction strategies, compared to how I did. (At the time, I was an experienced intrapartum nurse and a leader on a 600 births/month maternity service.)

According to HF standards, warnings--even bold ones using pictures with high-contrast color combinations and affixed in strategic locations--are insufficient if a higher-order strategy--like installing a protective grate north of the exit shoot--is feasible. Written directions (think: policies and procedures) similarly fall low on the list. Because written directions and warnings have a high failure rate, their best use is in conjunction with risk-reducing strategies that are more likely to work.

I think my jury service occurred in 1996 or 1997, several years before the publication of To Err is Human, an IOM report that quantified healthcare errors and served as a multi-stakeholder call-to-action. The subsequent 2001 report Crossing the Quality Chasm began to describe specific improvement strategies, previewing successes and borrowing methodologies from human factors-oriented industries, like commercial aviation and nuclear power.

In the mid-'90s, the idea that healthcare workers should do more than, "review policy" and "counsel individual" was revolutionary. But today, it shouldn't be.

Two years ago, Sean Berenholtz and Peter Pronovost, physicians at Johns Hopkins University and leaders in patient safety research, commented on interventions selected to prevent reoccurence of mistakes in healthcare settings, noting, "Unfortunately, weak interventions predominate and are often the same traditional solutions offered in a new package."1

Next time, I'll share more about a rank-ordering of risk reduction strategies that's used to promote medication safety. If I've piqued your interest, you can find a short case study and critique of the use of low-level risk reduction strategies in a June 2008 Pennsylvania Patient Safety Advisory.

In the meantime, stay safe working in your yard!


1 Berenholtz, B. & Pronovost, P. (2007). Monitoring patient safety. Critical Care Clinics, 23, 659-673.

Be Where You Are

I had planned to write about chipper-shredder mishaps today, sharing how a random call to jury duty introduced me to the discipline of Human Factors engineering and changed what I believe about people, lawn & garden equipment, and healthcare delivery systems.

Principles from human factors and cognitive psychology are important because they help to determine a rank order for risk reduction strategies. This helps clinicians identify the best strategies for preventing error, and helps administrators make provisions for endorsing, and funding, the risk-reduction strategies most likely to work. These are interesting things to talk about.

But sometimes, you've just have to be where you are. Today, I'm providing hospice care to our family's 12-year-old yellow Labrador retriever, Daisy. I'm trying to figure out the best plan of care and reviewing her recently acquired medication list in hopes of finding some hopeful explanation for her marked downturn. (Also cleaning up big messes, running the space heater, and trying to maintain a minimal-stim environment for Daisy, who prefers to stay curled up near, and occasionally on, my feet.)

We all regress under stress, I guess, and Daisy's working hard to stay connected. But when I'm "feeling" more than I care to, I become hyper-analytical, hoping to move back to the "thinking" place where I'm more comfortable. So I'll share a few nuggets from my unwelcome journey:

1. You can get medications for your pet at your local pharmacy. In the past, the medications our pets have needed all came from the vet's office, but when your pet moves into a high-octane plan of care, it turns out you can go to the same gas station where you get yourself fueled up. (At least you can do this in the state where I live.)

2. Pet medications are another variable in the look-alike packaging maze. Since this is a process-oriented blog, I'll invite you to look at the photo of Daisy's meds again. Notice how the one that came from the vet's office (on the right) has the distinctive pet silhouettes? I think this helps prevent distracted, stressed-out, and yes, tearful, pet owners from inadvertently taking their pet's medicine. The prescription on the left-hand side came from the real pharmacy, where my family gets our prescriptions filled. You can see that I flagged it to help me see--from a distance and maybe without my glasses on--that these pills belong to the dog. It would be better if all meds dispensed for canine use were placed in bottles like the one on the right.

3. Separate pets' medications from the family's stash. Maybe you are inherently less error-prone than I am, but the consequences of a mix-up could be huge. Separating look-alike containers is a stronger risk reduction strategy than simply trying to "be more careful."

Especially when you're crying.