Medication Mistakes Can Be Deadly But Preventable

bottleMedication error received national attention in 2007 when actor Dennis Quaid’s newborn twins were given a near-fatal overdose of the blood thinner heparin. The high-profile story highlighted the fact that medication error occurs with frightening regularity. Medication error is one of the top 10 causes of death in the United States, killing an estimated 7,000 people per year. More people die from medication errors than from motor vehicle accidents, breast cancer or AIDS, according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP).

Medication mistakes occur for any number of reasons. Staff members, overworked and exhausted, may miss critical details. Inattentive or rushed staffers might neglect to double-check their work. A trainee’s mistake may go unnoticed. Whatever the reasons, data published last year in the British Medical Journal found that injected medication errors occurred “with alarming frequency.” The study tracked 113 ICUs in 27 countries. In one 24-hour period alone, 861 errors involving 441 patients were reported. A dozen patients suffered permanent harm or death as a result of errors that occurred during administration. In addition to fatalities, medication errors may result in extended patient stays, additional treatment, and legal costs related to negligence or wrongful death lawsuits.

Companies such as MedAccuracy have developed products and services to reduce the incidence of medication errors in hospitals. MedAccuracy provides patient safety systems to healthcare facilities. The company’s AU MEDS solution uses a peer review system to detect medication errors. An employee of the healthcare facility is trained to observe and record medication administrations during regular rounds. The data is used to help facilities make adjustments to the way they operate.

Intravenous (IV) drugs are particularly vulnerable to human error. Patients may receive an incorrect dosage through a malfunctioning smartpump, as happened with the Quaid twins. The solution may have been formulated incorrectly in the hospital pharmacy. Patients may even receive the wrong formula altogether. Since IV solutions are clear, there’s no easy way to distinguish one drug from another. IV mistakes are involved in over 4,000 deaths in the U.S. each year. According to Michael Weickert, President and CEO of safety device maker SEA Medical Systems, the problem comes down to simple human nature. “Every one of those steps where people are entering data, mistakes happen,” says Weickert. “People are error-prone.”

SEA Medical is developing two products aimed at reducing IV-related errors. IVCheck uses a sensor and a drug database to analyze the contents of a formulation before it leaves the hospital pharmacy. No regulatory approval is required for the device, providing a shorter path to the market. SmartIV is a sensor that is placed on the IV line. It gives continuous reports on the properties and administration of the drug, providing nurses with a backup. SEA Medical has been testing its prototype system in medical centers around the U.S., including Brigham and Women’s Hospital in Boston and the Cleveland Clinic. Feedback so far has been “terrific,” says Weickert. The company is currently developing its next-generation prototype and experimenting with software to recognize the contents of an IV formulation. SEA Medical was one of the presenting companies at the 2010 OneMedForum in January. A video interview with Weickert can be viewed at the end of this post.

FHT (founded as ForHealth Technologies) seeks to reduce IV error through automation. The company offers Intellifill i.v., an automated system for the preparation of small-volume IV medications. IV formulations are manufactured in an aseptic environment and labeled with bar codes. The DoseEdge Pharmacy Workflow Manager is designed to track IV doses from order creation to the point of administration.

Alaris Medical, owned by CareFusion, markets a medication safety system for IV drugs. The system allows hospitals to create standardized infusion libraries, limit and check dose and duration, monitor patient respiratory levels in real time, analyze workflow, and more. Staff members can wirelessly retrieve infusion data from the system, which relies on one common user interface.

It may not be possible to completely eliminate medication error, but mistakes can be prevented. What can hospitals do to help improve patient safety?

Related video: Michael Weickert, President and CEO of SEA Medical Systems, discusses his company with OneMedTV correspondent Alicia Ontiveros at the 2010 OneMedForum.

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