Wednesday, May 14, 2008
Two drugs, one problem
Our head of pharmacy, Frank Mitrano, likes to say that he wishes that all drugs were packaged in exactly the same sized containers, with covers and lids of the same color, and with simple black lettering on a white background in the same font. Why? Because it is human nature to assume that a vial of medicine with a green cap and green lettering is, in fact, the medicine you were looking for, even if it is something quite different. And, also, the more layers of safety protection information systems and other technology that you have in place, the more likely you are to assume that you have the correct drug and the less likely you are to read -- in detail -- what the label actually says before administering the drug to a patient. On the other hand, if every vial were to look exactly the same, a human being would actually have to carefully read what is in it before administering a drug.
Here's the particular story that led Frank to say this today. Don't worry. No harm was done to any patient. But when we heard the story, there was some quick breathing.
Our obstetric service, like all others, uses Oxytocin to induce labor when it is necessary during childbirth. The service had made a practice of stocking each labor and delivery room with a vial of this medicine, in case it would be needed in a hurry. By mistake, one day, the wrong vial of medication was placed in each room. Instead of Oxytocin, a drug called Zemplar, generic name Paracalcitol, was placed in each room. Zemplar is a drug that suppresses the production of the thyroid hormone in a person. Giving a mother Zemplar instead of Oxytocin in the middle of labor would have been quite bad.
The good news is that a nurse noticed this error in one of the L&D rooms before any of the wrong medication was used, and she quickly notified everybody to check all the other rooms and take out the wrong medicine and replace it with the right one. Congratulations to her for her attentiveness.
But how could this happen in a hospital focused on reducing medication errors? Well, in the stockroom rack, medications are grouped alphabetically by generic name on the shelves. So Oxytocin and Paracalcitol are near each other. And look at the bottles above. Zemplar is on the left, and Oxytocin in on the right. Or is it the other way around? They are remarkably similar. So, it might have been a simple stocking error in the pharmacy which then cascaded down the distribution system until the wrong box was delivered to L&D, where the wrong vial was put in each room.
Multiple opportunities for error. In case you have wondered, yes, both the pharmacy folks and the L&D folks have been informed of this particular case. And steps have been put in place to make sure it does not repeat.
Meanwhile, in part of the hospital we have already replaced the manual stocking shelves with a computer controlled electronic stocking carousel that is designed to reduce this kind of error. And we will add this feature elsewhere, too. And, we are also moving towards bar-coding of every single dosage of medication so that it can be matched with the written order and the bar code on a patient's ID band.
But every electro-mechanical system has some flaw. The biggest flaw is that it creates an impression of security and precision that becomes a crutch upon which the medical staff relies. Frank Mitrano is not going to get his wish. So, ultimately, it will still be the responsibility of every single nurse and doctor to actually read the label on each dosage, compare it to the order given, and make sure each patient gets the right medication. Every time. Hundreds of thousands of times per year.
Posted by Paul Levy at 5/14/2008 06:09:00 PM