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Ken Margolin
Ken Margolin
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Solutions to the Medication Error Crisis

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Medication errors injure an estimated 1.5 million Americans each year. That staggering number is reported in studies conducted by the medical profession and pharmaceutical industries themselves. While there is no single cure for this terrible problem, borne ironically, of the tools used to cure disease, the steps to be taken to greatly reduce the problem have been understood for more than 10 years.

Better training of non-physician hospital personnel who mix, deliver, and administer drugs, is crucial. In order to cut costs, hospital pharmacy technicians who may be paid less than a pizza delivery driver, often have the responsibility to follow written directions and make the necessary measurements necessary to mix or dilute medications. Even in the age of computers, poor doctors’ handwriting is the source of many errors. Another major cause of errors is the simple misplacement of a decimal point. Computer cross-checking of safe dosage ranges, generally, and for a particular patient, can minimize decimal point errors. Absent computers, the simple expediency of using zeros when necessary for clarity, can help; for example, 0.25 milligrams, rather than .25, which might be carelessly misread as 2.5.
JCAHO, the hospital industry’s accreditation organization, has identified the following as leading causes of serious medication errors: Misread Prescription; drug taken from wrong vial; Milligrams (mg) in prescription read by health care worker preparing or administering the medication, as grams (g); improper dilution (or failure to dilute) adult strength drug administered to an infant; prescription misread because of poor handwriting – failure to call physician for clarification; wrong tube (from wall oxygen supply) connected to Import; Oxygen, rather than intended IV solution pumped into patient; zeros inadvertently added to intended prescription strength, for example, 12 mL read as 120 mL.
Some of the solutions being implemented by pharmaceutical, hospital, and medical professionals, to solve the problem are: (1) Improved training and education. Each pharmacist, physician, nurse, and pharmacy technician involved in the medication process – from production in the pharmacy to administration to the patient – is competent to perform the tasks he or she is assigned to perform; (2) Effective use of computers. Computers will be increasingly used to record patients’ prescriptions, drug allergies, and other pertinent information, and to alert health care providers when a prescription entered into the system for a given patient, appears inappropriate; (3) Unit dosing. Whenever possible, drugs should be individually packaged for specific patients, rather than prepared from stocks of medications, Primary use of unit dosing has radically lessened medication errors in some hospitals; (4) Improved analysis. Leaders in the field of medication error have realized that the causes of errors must be understood if the numbers of errors are to be significantly reduced. To that end, hospitals are being encouraged to clearly define what constitutes a medication error, to require that all errors be reported on standardized forms, and to analyze the underlying, systemic deficiency that caused or permitted the error to occur; (5) Collaboration with drug manufacturers. Many serious medication errors can be traced to labeling problems, such as labels cluttered with too much information, inadequate or obscured warnings, brand names of drugs for different purposes that sound alike. Representatives of the pharmaceutical industry and medical professions must collaborate on an on-going basis to identify and resolve potential problems before they contribute to a patient death or serious injury; (6) Recognizing medication error as a systems problem. Catastrophic medication errors are almost always due to systemic failures. While nurses and pharmacy technicians often commit specific errors, ultimate responsibility usually lies with the Pharmacy Chief or other hospital administrators who failed to devise adequate systems of error-prevention or who failed to adequately train and educate their personnel. The committment must be to insure that the number of serious medication errors in 2015 is far less than steadily shocking numbers from 1995 through the present.