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.


e-Patient Dave said...

Please see Randy Pausch's April 16 entry about the new bottle design used by Target pharmacies.

When I first saw that photo, I went "YIKES," recalling the similar-sized array of bottles I had a year ago; we depended on the differences in appearance. But you're right, if I'd had two similar-looking bottles, it could have caused trouble.

Anonymous said...

I happen to disagree with Frank, although I see his point. There is ample evidence that human error, whether a "lapse" (e.g. mental slip) or "mistake" (thinking about it, but making the wrong choice through lack of knowledge or other deficiency) is inevitable and exhortations only reduce it a certain amount. In the blood transfusion arena, for instance, exhorting the lab techs to read the patient's armband when they draw the blood for crossmatching, or the nurses to identify the patient before they transfuse the unit, have only limited effect - hence the proliferation of methods designed to overcome these inevitable errors.
Similarities in drug packaging are a known source of error. (example Dennis Quaid's twins and the heparin incident.) Rather than exhorting the caregiver to read the label (which, again, has been shown to have limited effectiveness), packaging and labeling should be nationally standardized to minimize the possibilities for human error.

Having a teenaged daughter, I am just realizing that this will become even more important with today's generation of young workers who key on colors, icons and other non-verbal cues rather than words. Although Frank may think it will force them to read, they will use almost any other cue first. We readers are shrinking inexorably - patient safety experts beware.

nonlocal MD

Anonymous said...

Most people assume that we see what there is to be seen by simply opening our eyes and looking. "Frank" is absolutely correct in suggesting that if one is forced to attend to the written label (as opposed to the cap color, bottle size etc) less errors would occur. The key term here is "attention." Empirical evidence bears this out - people are often unaware of surprisingly large, and potentially important events in their visual world when distracted. Indeed, studies in our lab have repeatedly demonstrated that just because an object is salient doesn't guarantee its detection. Rather, conscious perception requires attention.

Anonymous said...

While humans make mistakes, inadequate staffing should be considered to prevent such errors.