Medication Errors in the Spotlight

By Rodney Tanaka, Senior Communications Writer

POMONA, Calif. - 04/19/2010 -- Medication errors often result from system failures rather than one person’s mistake, and everyone is responsible for helping to prevent such problems.

That was the message from Michael Cohen, RPh, MS, ScD, president of The Institute for Safe Medication Practices (ISMP), keynote speaker for the fourth annual Ray Symposium at Western University of Health Sciences April 15, 2010.

The Ray Symposium is organized by the College of Pharmacy in honor of Max Ray, MS, PharmD, Dean Emeritus of the College of Pharmacy. He joined WesternU as Professor of Pharmacy Practice and Director of the Center for Pharmacy Practice and Development in 1996 and served as Dean of the College of Pharmacy from 1999 to 2006. The Ray Symposium is supported by an unrestricted educational grant from Watson Pharmaceuticals Inc.

ISMP operates a national medication error reporting program that allows practitioners – such as nurses, pharmacists and physicians – and consumers to report mistakes they made and mistakes they are aware of by others. All reports are confidential.

“In looking at errors, an effective approach would be, first of all, assuming that errors will occur,” Cohen said. “We all make them, whether we care to admit them or not.”

Medication errors aren’t the result of only one thing going wrong. They always have multiple factors and involve many different failures in the system, he said.

Sometimes a person will be punished for human error or other types of behavior that would not be considered negligent or reckless.

“Unfortunately, that’s the kind of thing that decreases an individual’s willingness and ability to come forward with information about improvements that are needed in the system, about errors that have happened or things that they feel need to be changed for patient safety purposes,” Cohen said. “People won’t do that if they feel they’re possibly in line for some sort of punishment if they do come forward, or if they’re going to be seen as complainers.”

The “sharp end” - the interface between the health care practitioner and the patient - is where the error often appears, Cohen said. But many times errors are rooted in the “blunt end” - system failures that are not under the control of the practitioner and may even be outside of the organization, Cohen said.

“Labeling and packaging issues that all of us have to face in practice can cause confusion and sometimes lead people to give the wrong medication,” he said. “Some of the policies in our hospitals would be on the blunt end. So all of this has to be recognized if you’re addressing medication errors, and too often the focus is on the sharp end instead.”

One example of addressing a packaging issue is Benadryl, an antihistamine made in several different forms to combat allergies and colds. At least seven people have been hospitalized for swallowing a gel form of Benadryl that should only be used topically.

ISMP posted this information on its consumer Web site and contacted the U.S. Food and Drug Administration and the company that produces Benadryl, Cohen said.

“The company is modifying the packaging so that it is not as easy to pour it out of the container,” he said. “They’ve also changed the labeling in many ways, and that should be reaching the store shelves soon.”

Another major ongoing problem is the misadministration of heparin, a blood thinner. Several deaths have been linked to inadvertent overdoses of the drug, most recently a 2-year-old in Nebraska in March. Actor Dennis Quaid’s infant twins nearly died because they were given a heparin concentration 1,000 times greater than it should have been, Cohen said. The incident prompted Quaid to become a patient safety advocate.

ISMP examined more than 100 instances of heparin problems and developed a table detailing common risks and key improvements that could prevent errors and deaths.

“We’re hoping that hospitals, organizations and multidisciplinary committees will take the time to look at this so that the next one doesn’t happen,” he said.

To improve safety, ISMP recommends being proactive and learning from the experiences of other organizations, focusing on unsafe practices and at-risk behaviors and encouraging error reporting.

“Probably for me the most frustrating thing of all is this information is out there, but for too many hospitals it’s about reacting to the next error rather than being proactive and preventing it,” Cohen said. “And that’s got to change. For some reason we have been unable to convince certain individuals in certain organizations that this is absolutely paramount to preventing many of these fatal errors.”


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