Med: Medical errors are not always doctors’ fault

November 21, 2007

Hey everyone,

I’m not usually the type of person that invests too much time into the lives of celebrities; however, this latest example really caught my eye/ear. I was listening to the radio, and a brief mention was given to the fact that Dennis Quaid’s newborn twins were given a 1000x dosage of “some drug.”

I immediately thought back to the AMSA conference and one of the issues brought up by Dr. Tim MacDonald–the Associate Chief Medical Officer of Safety and Risk Management at UIH. He mentioned a potential problem in the labeling/packaging of the drug Heparin. Heparin is a blood thinner used in adults; however, there is a 1000x smaller dose version called Heplock used to simply keep IVs/ports open in newborns. The bottles look VERY similar, and one can be easily confused with the other.Looking into the Quaid issue, it appears something like this happened. The article that I link below doesn’t specifically mention Heplock (only Heparin), but given the circumstances it seems very likely that this is the case.

http://www.cnn.com/2007/SHOWBIZ/Movies/11/21/quaid.newborns.ap/index.html

I bring this up to make a few points. First, the fact that the bottles for 1000x different doses of the same drug are made to look similar is complete idiocy. But I also want to make the point that medical errors are not always the result of negligence on the part of a doctor.

For example–regarding Heplock–Dr. MacDonald presented this scenario (which is what I believe occurred here in Chicago a few years ago):The problem begins with the person stocking the shelves of the medical supply room. This isn’t the doctor and may not even be a registered nurse–it could just be a random hospital employee. Envision an overworked/unpaid supply room person that takes these similar bottles and accidentally puts them on the same shelf thinking that they’re the same. Then when a doctor writes an order for Heplock, the nurse runs into the room and pulls one quickly down from the shelf–forgetting to check it. And then a doctor–also overworked/tired/stressed, happens to not check the medicine before it’s administered.

Being early in my medical career, I’m not sure if a doctor is “supposed” to check it or if the trust is simply placed on the nursing staff to deliver it correctly. In my mind, a doctor that prescribes a med should see it before it’s given.

So where do you place the blame is this situation? Perhaps the doctor should have performed a final check. And surely the nurse should have actually made sure that she/he grabbed the correct med. And of course hospitals depend on the supply room staff to get the job done quickly and correctly.

This isn’t on one person–it’s a systemic breakdown.And it highlights the need to move everything into the electronic realm. It goes something like this:

a) Doctor puts order for Heplock into the computer.

b) Nurse sees the order, and goes to the supply room to get it (Also, there could could an electronic aspect to the supply room).

c) When the nurse reenters the patient’s room, she must scan in–think barcodes–all meds that she is now carrying. If she has Heparin instead of Heplock, the computer goes crazy, alarms sound, and that medicine never even makes it close to being administered.

How hard could a system like this actually be to set up?

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5 Responses to “Med: Medical errors are not always doctors’ fault”

  1. anonymous said

    which medicines exactly do you think the doctor will be personally checking? 😆
    all of them? iv only?

  2. Carol said

    actually, some pharmacies in my town have a system similar to that for dispensing.

  3. martygrn said

    I can tell you as an RN who has worked in many different hospitals all over the country (I am a travel nurse), that the responsibility for administering the drug after the order is written falls squarely on the backs of the nurses. I have yet to see a single physician, from attending to med student, who has ever checked a med of any kind. The high-alert meds (KCl, Digoxin, Narcs, etc.) are required to be double-checked by another RN. As to why the med was in the nursery, this is a very fair question. Were the babies in the newborn nursery or a pediatric unit? If a pediatric unit, remember, we must have stock for patients ranging in age from newborn to 17+ yrs old. That concentration may be appropriate for some teenagers. We use the heparin pre-filled syringes all the time for KVO purposes and do not even need a physician order to do so. It is protocol. The pre-filled syringes only come in two concentrations: 10U/1 mL and 100U/1mL. OF course, the prefilled syringes cost a bit more, but how much is safety worth?

    As for the bar-code systems, they do exists but are VERY expensive to implement. You have the initial cost of how many hundreds of computer terminals and associated hardware, but also software licensing for those very same computers. Also, the systems must communicate with some sort of patient management software so it knows the patients weight, doctors orders, etc. The cost to implement med barcoding for most hospitals comes to the tune of multi-millions.

  4. kurzman85 said

    martygm-

    Thank you very much for that response–it was very helpful and insightful.

  5. NL said

    As a product and graphic designer, I will tell you that the manuf. of the drug is just as, if not more, responsible than the nurse who administered the drug.

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