March 7, 2007
Medication Errors Are Studied
Young children are the most likely victims of surgery-related medication mistakes, a new study has found, and poor communication as the patient moves from the operating room to recovery is the most likely culprit.
The study, released yesterday, was done by the United States Pharmacopeia, which sets standards for the pharmaceutical industry, and by the Uniformed Services University of the Health Sciences in Bethesda, Md., and two nurses’ associations.
Medical error has been a charged topic ever since a 1999 report by the Institute of Medicine , “To Err Is Human,” estimated that such mistakes led to as many as 98,000 deaths a year — more than highway accidents and breast cancer combined.
The current study did not try to estimate total error rates. Instead, it analyzed 11,000 mistakes that had been voluntarily and anonymously reported to the pharmacopeia by hundreds of hospitals since 1998.
The study was confined to errors made on patients undergoing surgery, and the rate of harm, 5 percent, was much higher than is typical for medication errors. Among children it was 12 percent.
Problems typically arose when a patient was handed off from the preoperative team to the operating room to the recovery room to the regular ward nurses , said Diane Cousins, a health care specialist at the pharmacopeia and one of the authors. “The system is often very fragmented ,” Ms. Cousins said.
Typical dangerous mistakes were failures to administer antibiotics before surgery, failures to note allergies , errors in setting pumps that dispense blood thinners or painkillers, and giving overdoses to infants.
In several cases described in the report, poor penmanship, careless listening or bad arithmetic caused patients to get doses 10 or even 50 times as high as they should.
“It’s beyond troubling that the smallest, youngest patients are the ones most at risk ,” Ms. Cousins said.
There are 10,000 drugs in the marketplace, she said, and many have never been tested on children in clinical trials, so doses are often made by guesswork based on weight, involving conversion of pounds to kilograms, sometimes by nurses who are not pediatric specialists . [or may be ex-Job Lot employees?]
“These may be back-of-the-envelope calculations not checked by anyone ,” she said, “and they are often in very tiny amounts — milliliters — and that in itself breeds errors.”
The report made 42 recommendations, among them that hospitals improve communication and designate a pharmacist to be consulted for each patient.
Since 1999, committees investigating medical mistakes have routinely recommended that hospitals install computerized systems for prescribing drugs, which can sound alarms when a toxic combination is ordered for a patient. But fewer than 10 percent of all hospitals have them.