Last November, Dennis and Kimberly Quaid's newborn twins received about 1,000 times the recommended dose of heparin, a drug used to flush out medication IV lines and prevent blood clotting problems, when they were hospitalized for staph infections at Cedars Sinai Medical Center in Los Angeles.
Shortly after the twins were released from the hospital last year (they are now doing fine), Dennis and Kimberly set up The Quaid Foundation (www.thequaidfoundation.org), dedicated to reducing medical mistakes. They are dedicated to the cause, combing through medical journals and statistical reports and visiting model programs striving to fundamentally address the problem by stopping errors at the source. And last May, Dennis testified before Congress, voicing his strong opposition to the concept of preemption for pharmaceutical companies.
Opponents of applying preemption to pharmaceutical companies say it will undermine a patient's ability to sue if harmed by a drug; proponents say the possibilities of lawsuits after a prescription medication has been approved stifle innovation and say preemption won't deny patients legal redress.
A court case, Wyeth v. Levine, due to be heard by the U.S. Supreme Court this fall, will rule on that concept of preemption and whether it holds true for pharmaceutical companies.
What can be done to reduce errors?
Safety experts most often mention two approaches to reducing medical errors: bar coding systems and computerized physician-order entry systems.
Put simply, bar coding involves a healthcare worker’s going through a series of checks before giving a patient a drug—scanning his own bar-coded badge, the patient’s bar-coded wristband, and the medication bar code, then pulling up the patient’s computerized medical record to be sure it’s the right drug, right dose, and correct time to give it. If there is a conflict, the computer sends an error message.
Only about 13% of the nation’s hospitals have a fully implemented bar code medication administration technology, according to the American Society of Health-System Pharmacists, but more are moving toward it.
Computerized physician-order entry involves a doctor entering the order on a computer and takes the place of handwritten orders, which can be misinterpreted, experts say.
Dennis and Kimberly flew to Texas in July to tour Children’s Medical Center Dallas, which is launching a new bar coding system. The couple personally observed the system of built-in checks as they followed the process of ordering a drug through administering it to a patient, Quaid tells WebMD.
“The nurses there told me they resisted it at first. But now, they say they wouldn’t want to give a medication to a patient without using the new system.” Besides the general resistance many people have to new technology, some nurses cite the extra time needed to scan medications but then see that the added effort pays off in reduced risk of error.
What can you do?
Unfortunately, those errors continue to happen, and more often than you might think. The statistic sounds unbelievable: On average, a patient in a U.S. hospital will be subject to one medication error a day. Some mistakes may be small and mostly inconsequential; others may be deadly.
Although much of the burden rests on hospital staff and computer systems, patients and their families can take steps, too. Among Dennis and Kimberly Quaids' tips:
- Be there. Stay with the patient at all times. Never leave a hospitalized friend or relative alone.
- Ask questions. Don’t worry about sounding nosy or seeming annoying. People should memorize the ”five rights“ of medication safety -- right patient, right drug, right dose, right route (such as IV, oral), right time. That won't guarantee safety, but it will help.
- Know your rights. And enforce them. These include the right to see your medical records.
- Go with your gut. If it seems like the wrong time for a medication, or if the medicine suddenly looks different, ask questions before accepting it or before letting your friend or relative accept it.
(Adapted from WebMD the Magazine’s September/October 2008 issue. Read the complete story here.)
