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    Medical and medication errors - “60 minutes” examines dennis quaid’s twins’ near fatal heparin overdoses


    This past Sunday, CBS’ “60 Minutes” program took a look at the unfortunate medication errors that nearly killed actor Dennis Quaid’s infant twins last November at Cedars-Sinai hospital in Los Angeles. The babies were in the hospital to receive intravenous antibiotics for a staph infection when they were accidentally injected with adult strength heparin, a blood thinner, which was 1000 times the dose they should have received. The overdose caused the children to have bruising and bleeding, but, fortunately, the mistake was recognized and the treatment was effective and they recovered with no apparent permanent effects. That wasn’t the outcome for three infants who died at Methodist hospital in Indianapolis last year who also received accidental overdoses of heparin (three other babies at Methodist also got heparin overdoses but they recovered).
    In fact, following the Methodist hospital incident, Baxter, the heparin manufacturer, put special labels on all new vials of adult heparin, which warn users not to administer them to infants. They also issued a detailed warning letter to all hospitals alerting them to the potential confusion that might still occur with existing heparin vials because the labels are so similar, but they did not recall the existing vials. Quaid is suing Baxter, presumably for not recalling the potentially confusing vials. Baxter denies any wrongdoing, and notes that hundreds of thousands of doses of heparin are used daily in hospitals without incident and that it took fully three separate human errors at Cedars for the Quaid infants to receive the incorrect dose.
    Unfortunately, however, preventable medication errors are all too common in the United States. The Institute of Medicine (IOM) estimated in their July 2006 report entitled Preventing Medication Errors, that there are at least 1.5 million preventable adverse drug events in the U.S. every year (and they acknowledge that this is likely an underestimate). The IOM concluded that since these errors are preventable and since various methods already exist to prevent them, that “the current state of affairs is not acceptable.” They recommended a series of steps that should be taken to prevent medication errors.
    The first step recommended by the IOM is to encourage patients to take a more active role in their own healthcare, to understand more about their medications and to take more responsibility for monitoring those medications, while providers should take steps to educate, consult with, and listen to their patients. “Doctors, nurses, pharmacists and other providers must communicate more with patients at every step of the way and make that communication a two-way street, listening to the patients as well as talking to them. They should inform their patients fully about the risks, contraindications, and possible side effects of the medications they are taking and what to do if they experience a side effect. They should also be more forthcoming when medication errors have occurred and explain what the consequences have been.”
    The second step is to greatly increase the use of computerized information technologies in the prescribing and dispensing of medications. Computer databases can be used to obtain current accurate information about drugs, about the patient, about the other drugs the patient is receiving or is allergic to, and any special warnings that might exist regarding the medications. In addition, using electronic prescriptions can greatly reduce the potential for errors due to misreading written prescriptions, an all too common occurrence. Moreover, tying electronic prescriptions to the previously mentioned databases could automatically generate warnings about improper prescribing for individual patients. The IOM recommended in 2006 that by 2010 all prescribers and pharmacies should be using electronic prescriptions.
    Because of the amount of medication used today, both in hospitals, and in the out patient setting, and the number of people involved in their prescription, distribution and use, it is inevitable that mistakes will happen. We all need to be aware of this possibility and need to do what we can to avoid them. You should try to be as informed as possible about any medications that are prescribed for you including their names and their dosages. You can only do that if you either are told by the physician or you ask to be told exactly what they prescribed. And then you should double-check to ensure that what you get at the pharmacy is what your doctor ordered.
    Have you had experiences with preventable medication errors, either in hospitals, nursing homes or as an out patient? Please tell us about what happened. Other HealthTalk readers might gain important information from your story. We look forward to hearing from you.
    Sources:
    Institute of Medicine Report: Preventing Medication Errors
    60 Minutes: Dennis Quaild Recounts Twins’ Drug Ordeal (Source: Dr. Z's Medical Report)

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