Dispensing
Medications: An Exercise in Error
By
Amanda Gardner
MONDAY, July 15 (HealthScoutNews) -- It was every
patient's nightmare. A 68-year-old, non-diabetic
woman who had just had elective bypass surgery was
given insulin instead of the anticoagulant heparin
to flush her arteries. The insulin sent the woman's
blood sugar plummeting; she fell into a coma and
died seven weeks later, when her family decided
to stop life support.
Medication mistakes are fairly common in hospitals,
but most of them are not life-threatening, says
an article in tomorrow's issue of Annals of Internal
Medicine, the second in a series examining medical
errors.
Although the medication-dispensing process varies
widely not only between facilities but also within
them, errors can occur at any of a number of points,
the article says.
In the hematology department of the Ochsner Clinic
in Baton Rouge, La., for example, most prescriptions
are handwritten by the doctor, then typed into a
computer by a low-paid clerk who may or may not
have trouble reading the handwriting. The typed
information is then transmitted to the pharmacy,
where a technician begins the process of dispensing.
"If it's a pill, that's pretty simple,"
says Dr. Jay Brooks, chief of hematology/oncology
at the clinic. "But if it's a mixture in a
bag of fluids, it's more complicated because you
have the actual mixing, then the proper labeling,
then it has to go back to the floor" where
you have to assume the nurse or other staff member
who actually administers the medicine follows proper
instructions.
"You can see that this whole process is fraught
with possible errors," Brooks adds.
In the case of the 68-year-old bypass patient, several
factors contributed to the fatal error, including
a failure to store the medications properly -- the
heparin and insulin vials were on top of a medication
cart and, apparently, mistaking the two drugs is
common.
"Both of these drugs are used frequently, and
the vials they're kept in look somewhat similar,
and the medications are often not kept in secure
places because it's more expedient," says Dr.
David Bates, lead author of the study and the chief
of general internal medicine at Brigham and Women's
Hospital in Boston.
Most hospitals have many checks to help ensure errors
aren't happening. Often the nurse on the floor will
double-check with what the clerk typed in the computer.
The pharmacist will call the doctor if he feels
a request seems strange. If Brooks is writing an
out-of-the-ordinary prescription, he will often
attach the journal article that explains the request
or he'll call the pharmacist directly.
When Brooks uses heparin and the pain medication
Lidocaine in bone marrow procedures, he insists
on a standing routine: The medical technologist
picks up a vial, looks at the label, faces the label
towards the doctor, and says the drug name out loud.
"It's a very rote thing but, we do it so I'm
not giving the patient heparin for her pain medicine,"
Brooks says.
The Annals of Internal Medicine article identified
a number of things that might have prevented the
mistake, including instituting protocols for medication
administration.
A number of hospitals have started implementing
bar coding like that found in supermarkets, Bates
says. Unfortunately, manufacturers do not routinely
provide drugs with bar codes, so the hospitals and
clinics have to do it themselves at considerable
expense.
Bar coding would help, Bates adds, but other things
might help more.
"The single most beneficial change in terms
of medication process is to get physicians to order
medications using the computer, so that the orders
can be checked for allergies and other problems,"
he says.
This would not have altered the fate of the 68-year-old
woman, but it would help with more common types
of errors: If patients have adverse reactions to
drugs or they receive the wrong dosage.
"Computerizing really does help with this,"
Bates says. |
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