Ask the nurse to check the dosage

In a repeat of a case in Indiana last year, in which three babies died, the newborn twins of a well-known actor were administered an overdose of heparin, a generic drug used as blood thinner.

These and other cases illustrate what seems to be a growing problem in healthcare: medication errors.

The Institute of Medicine reports that every year, over 1.5 million Americans are victims of wrong medication or incorrect doses which led to extended hospitalizations. The number of incidents in recent years is twice that in the last decade.

According to the Archives of Internal Medicine, serious injuries linked to medication errors have surged from approximately 35,000 in 1998 to almost 90,000 seven years later in 2005. Out of these serious injuries, there were 5,000 deaths in 1998 (or slightly over 14%) rising to more than 15,000 deaths in 2005 (nearly 17%).

Medication errors often happen when pharmacists do not stock drugs properly, nurses do not make sure they’re administering the correct medication or the proper dosage, and doctors write so badly their instructions are misunderstood.

In the recent case in California and last year’s case in Indiana, the heparin dose administered was 10,000 units per milliliter when it should have been 10 units per milliliter. The packaging for both units was so similar it was so easy to make a mistake. They were accidents waiting to happen.

The United States Pharmacopeia documents heparin as being one of five drugs that are usually wrongly administered. The other four are insulin, potassium chloride, morphine, and warfarin. These five occur in 28% of all cases of medication errors. All five can injure patients, when erroneously administered.

A professor of health policy and management says errors in hospitals are not uncommon, and the healthcare system must work towards improving patient safety. Medication errors increase in likelihood because four of five Americans take some form of medication not less than once a week. At least six billion prescriptions are written each year in the US.

Some possible ways to reduce medication errors are:

* Make packaging conspicuously different for similar/related drugs.
* Place bar codes on medications. Hospitals should install bar code systems; they are costly, but they help immensely.
* Eliminate highly concentrated doses from wards to eliminate risks of accidental use.
* Require two healthcare professionals to verify medication during dispensing from the pharmacy and before administering doses.
* Install computerized physical order entry systems, where doctors directly type prescriptions into a computer. The computer program alerts the physician if the prescribed doses are outside normal range; this also eliminates errors due to misreading of prescriptions.

Safety Tip:
* If you are a patient, tell the nurse to double-check that the medication being given to you is meant for you.
* Ask the nurse to check if the dosage is right.