Friday, September 22, 2006

Real example of medication error should be used as learning tool

Imagine being the nurses who inadvertently gave two newborns deadly doses of Heparin at an Indianapolis Hospital earlier this week.

Or the hospital’s Chief Executive Officer, who went on national television to apologize for the error.

Or, even worse, the families who have to live with the mistakes – and without their beloved children – for the rest of their lives.

“This real-life situation magnifies the devastating impact medication errors can have, and underscores the need for Hospital staff to take all precautions possible to ensure the “five rights” –- the right medication, right dose, right patient, right route of delivery, right time,” said Peter Shea, MD, Medical Director at Backus. “Following procedure is the foundation of error prevention. Everyone should be sure to look at and read the label on everything that is administered and check it against the MAR -– it is there to protect patients and staff.”

While Backus Hospital has spent a lot of time improving its systems, protocols and technology to decrease the chances of medication errors, staff must always remain cognizant of the possibility of human error, said Karen Long, RN, Vice President and Chief Nursing Officer.

“As healthcare professionals, we should all take a long, hard look at this tragic event and use it as an educational opportunity going forward,” said Ms. Long said. “I am sure that everyone involved in this tragedy would give anything to be able to go back and follow the processes they might have thought were

Mary Bylone, RN, Assistant Vice President, Patient Care Services and Patient Safety Officer at Backus, said this particular situation, in which adult doses of Heparin were mistakenly given, clearly illustrates the human factor that the Institute for Medicine says is at least partially responsible for 40 percent of all medication errors nationwide.

The hospital unit that administered the drug usually only received doses of Heparin for newborns, and the vials of adult and baby doses are of similar size and color, so the nurses allegedly assumed they were correct, Ms. Bylone said.

“Despite all of the attention and time we have spent medication errors, and all the systems we have changed, it still comes down to you having to check the medication before you administer it,” said Ms. Bylone, who recently authored a column in Advance for Nurses magazine about medication errors, and how the “human
factor” commonly plays a role in them.

“We can’t simply sit back and wait for our employer to send us to another in-service,” Ms. Bylone wrote in the column. “We owe it to our patients to actively and continuously seek out the latest information regarding medications.”

Anyone with questions about medication safety, or suggestions to improve patient safety overall at Backus, can call Ms. Bylone at ext. 2771 or Joe Hughes, Director of Quality Improvement, at ext. 2345.


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