The University of California in San Francisco has recently instituted a program to improve accuracy in administering drugs, with a particular focus on reducing distractions or interruptions that may cause medical negligence.  Nurses at California hospitals have complained that distractions while giving medications to patients may result in serious injury or death – caused by giving the wrong medication or improper administration or regimen.  The UCSF program as resulted in approximately 88 percent drop in errors over three years at the Bay Area hospitals. 

Some hospitals employed low-tech methods, such as covering up the windows in the medication room so as not to be distracted by colleagues waving hello, or wearing bright colored vests while dispensing medication.  Others use high-tech methods, such as bar code scanners.

The study and its participants demonstrate that patient safety can be maximized by applying common sense and helpful visual cues.  The hospitals now follow “best practice” principles, including checking two forms of patient identification before administering drugs and explaining each medication to the patient.  Hopefully, more hospitals will follow such practices to prevent patients from being injured or killed by the wrong medication.

Another recent peer-reviewed study by Accredo Health Group and several university hospitals highlights how the wrong medication and other administration errors can be life-threatening.   The study showed how patients being treated for pulmonary arterial hypertension (PAH) with infused drugs have been suffered serious injury or death from medication errors in hospitals.  The study was presented at the American College of Chest Physicians’ annual meeting and will be published in CHEST, a medical journal.

PAH is a debilitating, life-threatening condition that can lead to heart failure and lung transplants.  The condition must be treated with epoprostenol (Flolan) and treprostinil (Remodulin), infused drugs that inhibit the blood from clotting and also widen blood vessels to ease blood pressure.  The drugs must be continuously infused into the body, and the drugs are dosed in extremely small quantities.  Giving a patient too much or too little can lead to serious injury or death.

The study showed that medication errors occurred in large numbers, including providing the wrong drug to patients, improper dosing, incorrectly flushing the patient’s catheter line and accidental stoppage of the infusion pump.  Researchers recommended the following to prevent patients from being given the wrong medication and injured or killed as a result:  better training, double-checking dosage, color-coding different drugs, ensuring the infusion pumps work correctly, and better record-keeping.

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