Catching Deadly Drug Mistakes

Look-alike packages for eye medications include those for three different types of antibiotics and an antiviral drug for the herpes virus.

By LAURA LANDRO
WSJ

A nurse misunderstands an abbreviation on a pharmacy order, and gives an accidental overdose of a drug that slows the heart rate, killing the patient. Intravenous fluids are administered after surgery at too-high a rate to a child, who then dies because of the error. Confusion over a drug name leads to insulin being added to infant nutrition IV solutions instead of the intended medication, heparin, an anti-clotting drug: The consequences are fatal.

Despite years of effort to make medications safer, mishaps like these still happen at an alarming rate. Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States, according to the Food and Drug Administration. Now, new efforts are underway to quickly spread the word about such errors and offer guidance on how to prevent similar mistakes.

The non-profit Institute for Safe Medication Practices, which is certified by the federal government to collect error reports and other information about quality breaches, and the American Society of Health-System Pharmacists are launching a new National Alert Network for Serious Medication Errors. The network, which was unveiled last month, will be used to send email alerts to 35,000 pharmacists working in hospitals and health systems, as well as physicians and nurses, when a dangerous or life-threatening error is reported to ISMP. The two organizations are also in discussions to extend the network to as many as 26 other organizations that promote safe medication use. The hope is that widely spreading the word about such errors will cause doctors and pharmacists to be more cautious—and ultimately prevent future mix-ups. Relevant alerts will also be sent to 20,000 drugstore pharmacists.

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