Research shows up to 90 percent of Americans fall short in getting important nutrients from food alone (Vitamins A, C, D, E).
Medical error is clearly the Number One problem in healthcare, contributing to more deaths in the USA than motor vehicle accidents, falls, drowning and plane crashes combinedsee Figure 1 below. Most medical errors are related to system problems, not individual negligence or misconduct, and are preventable (see our other Summary Statistic on the preventability of adverse events). Zegers M, Bruijne MC de, Wagner C, Hoonhout LHF, Waaijman R, Smits M, Hout FAG, Zwaan L, Christiaans-Dingelhoff I, Timmermans DRM, Groenewegen PP, Wal G van der.
Last month, a research team from Massachusetts General Hospital published a study in the journal Anesthesiology suggesting that medication errors had the potential to occur in almost half of all surgeries. According to an article from Bloomberg, the team observed over 270 of the procedures performed at Massachusetts General and noticed medication errors occurring at shocking rates.
Even worse: Over one-third of those errors hurt patients in some way, whether the mistake affected their vital signs or put them at increased risk of infection. While no one died because of the surgical team’s medication mistakes, three patients were actually put in life-threatening situations. The syringes administered to the patients were supposed to be filled with morphine sulfate.
In fact, according to Michael Cohen, president of the Institute for Safe Medication Practices (who was quoted in the Tribune’s article), some healthcare professionals don’t even realize there’s a difference between the two.
But the worst part about Butler Memorial’s mistake: There were two chances to make it right.
Initially, the staffer only placed 15 prefilled syringes with hydromorphone into the wrong container. Separate groups of hospital clinical staff retrieved needles from each container – and not one person verified they contained the correct drug and dosage.
As a state inspection report about the safety violation stated: “The staff failed to ensure patient safety and meet the needs of patients” by not following proper medication safety protocol.
The hospital is currently following a corrective action plan to keep a mistake of this magnitude from happening again. Since the stakes are so high, it’s crucial for hospitals to get medication dosage right the first time. In addition, certain electronic health records (EHR) systems have built-in alerts if a patient’s prescribed a drug in error due to allergies or drug interaction issues. But ultimately, clinical staff can’t go wrong by following Cohen’s classic advice: “We always tell people to read the label. Errors involving medication administration can be costly, both financially and in human terms. When asked to identify the most common factors that contribute to injectable medication errors, 78 percent of nurses surveyed cite their rushed workload and busy environment.
In this three-part series, Health investigates why more than 100,000 people a year are dying from medical errors and millions are being injured, what safety measures may help, and how you can protect yourself during your three points of vulnerability—at the hospital, your doctor’s office, and the drugstore.
The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study.
Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. In fact, one recent medication error at a Pennsylvania hospital put patients in “immediate jeopardy,” as stated by hospital officials. Instead of the actual narcotic prescribed by their doctors, patients at Butler Memorial Hospital accidentally received injections of a drug that’s seven times more powerful. But a staffer put syringes filled with potent pain killer Dilaudid inside a storage dispenser instead. A few minutes later, someone put three additional hydromorphone syringes in a different, incorrect container.
It includes intensive retraining and monitoring to make sure safe medication dispensing practices don’t fall through the cracks.
Many facilities have cut down on errors by using bar-code technology to scan each drug before giving it to patients.
The establishment of a hospital patient safety program that includes medication labeling protocols can help to reduce such errors, which can range from a patient receiving an incorrect dosage of a medication to receiving incorrect medication.
Eighteen patients were medicated with these syringes before the hospital discovered the problem.
For more information, review The Joint Commission's 2006 Critical Access Hospital and Hospital National Patient Safety Goals, which includes suggestions for how to avoid medication administration errors.
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