11/21/2007

ASHP Responds to Medication Errors Harming Actor's Babies

The recent medication error involving dangerous doses of heparin to the newborn children of actor Dennis Quaid announced today highlight the continuing imperative to make real progress in eliminating medication errors.

“How many wake-up calls do we need?” asked Henri R. Manasse, Jr., Ph.D., Sc.D, Executive Vice President and CEO for the American Society of Health-System Pharmacists (ASHP).  “What keeps us up at night is that we know how to prevent these serious errors.  Yet here we are again, facing the exact same error that killed three infants one year ago in Indiana.”

ASHP has long called for hospitals and health systems to institute known safeguards and system approaches to create a fail-safe medication-use system.  “Babies are being injured and even dying for no reason,” said Kasey Thompson, Pharm.D., ASHP Director of Practice Standards and Quality.  “We know how to put an end to it and we must do it.  Hospital boards of trustees and CEOs must take this seriously and act now,” said Thompson.  “It’s important to remember that there are extremely well-qualified and careful staff at hospitals throughout the country,” Thompson adds.  “These problems are caused by bad systems, not bad people.”

ASHP had already been planning an “IV Safety Summit” for this coming spring, pulling together a group of key stakeholders, including the Institute for Safe Medication Practices, the Joint Commission, the National Patient Safety Foundation, the Infusion Nurses Society, Brigham and Women's Hospital Center of Excellence for Patient Safety Research and Practice Center of Excellence for Patient Safety Research and Practice, and the U.S. Pharmacopeia to tackle this very issue.

ASHP recommends the following steps be instituted in all hospitals:

  • Involve pharmacists in the design and evaluation of all medication-use processes. ASHP has developed a task analysis for this activity.
  • Use the strongest preventive strategies, such as forcing functions or constraints, in processes involving high-risk drugs such as heparin and high-risk patients such as newborns.
  • Limit the number of concentrations of medication available on patient care units to the one most frequently used and dispense the others from the pharmacy.
  • Dispense medications in ready-to-use (unit dose) form prepared by the pharmacy. Limit, to the extent possible, any additional preparation steps prior to administration.
  • Always label medications with the drug name and strength if not given immediately
  • Implement barcode bedside scanning technology.  Nearly 20 percent of hospitals use this technology, up from 1.5 percent since 2002. 1
  • Simplify and standardize processes for medication use.
  • Seek and use knowledge from other institutions that have solved similar problems.
  • Assess the potential for error during selection, storage, preparation, and administration in areas where the medication will be used, including medications in automated dispensing machines.  The appearance of both the outer package and immediate container should be compared to other stored medications to avoid look-alike mix-ups.
  • Report all actual and potential errors.  Use the “lessons learned” to improve the safety of medication use.


1Pedersen, C., Schneider, P., Scheckelhoff, D. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2005. Am. J. Health Syst. Pharm., Feb 2006; 63: 327 - 345.

 


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