You Say Aspirin, I Say Heparin

Aspirin or heparin? Hydrocortone or Hydrocodone? Vioxx or Zyvox, or, maybe, Ziox? You'd think doctors, nurses and pharmacists would be able to keep these things straight--isn't that what they go to school for?--but in the chaos of a busy emergency room, or filtered through a noisy cell-phone connection, it's not surprising that communications sometimes go awry. For that matter, we ought to be able to keep these things straight ourselves, but patients waking up at 6 a.m. and stumbling into the bathroom to take a Zestril have been known to take a Zyrtec or a Zetia instead.

U.S. Pharmacopeia (USP), the nonprofit organization that sets national standards for purity and strength for drugs, tracked 26,000 incidents of patients receiving the wrong medication over a four-year period. (The study looked at a sample of about 10 percent of the nation's hospitals.) In 1.4 percent of those cases, a patient was harmed--occasionally, although rarely, fatally.

And the problem is growing, as hundreds of new drugs each year join the thousands already on the market but with no corresponding addition to the letters of the English alphabet. The last time USP examined the problem of look-alike and sound-alike drugs, in 2004, they found 1,750 pairs of potentially confusing names; this time there were 3,170, and they included, according to USP chief science officer Darrel Abernethy, each of the top 10 drugs sold in the United States.

How does it happen? USP's study found 71 different causes of error, including such nonobvious ones as "storage proximity errors"--people reaching for the bottle next to the one they wanted. Consider one case described by Dr. Julius Pham of Johns Hopkins involving a patient resuscitated after cardiac arrest. "A situation like that is chaotic, things need to occur rapidly, communication is all verbal," said Pham, who was in the ER that day. He ordered an IV of Levophed, a drug used to boost blood pressure rapidly, but the patient failed to respond. He ordered the dosage increased, then increased again, and as he looked over at the bag, he saw to his horror it actually contained Levaquin, an antibiotic. "For 10 minutes we were giving this patient an antibiotic," Pham said, adding: "this patient did not do well."

A trauma team or an ICU staff is supposed to work like a well-oiled machine, Pham says, so that when a doctor orders "neo," the nurse will know, depending on the situation, whether he means Neosynephrine to raise blood pressure or Neostigmine to reverse the effects of muscle relaxants after surgery or the antibiotic Neomycin. But it's worth asking whether the savings in time by lopping off two syllables is worth the risk of a disastrous mistake.

Compare this to another system that people routinely entrust their lives to, commercial aviation. Before taking off or landing, pilots run down a written checklist. They don't rely on their memories and they don't ask if the watchamacallits are set, and maybe doctors shouldn't be doing that either, according to Steve Harden, a commercial pilot and former Navy flight instructor who is president of LifeWings Partners. Harden's Memphis, Tenn.-based company, which he founded in 1999, is attempting to bring to health care the same standards of precision that are routine in the military and in aviation. "That means checklists, written protocols, standardized scripts," he says. "Almost 70 percent of the mistakes in hospitals have as one of their major root causes a communications breakdown or flaw. So you script the communication process so you get good communication. Specific words mean specific things."

Harden has one suggestion that USP also endorses, changing the names of some drugs that are especially prone to confusion. Where that's not possible, he says, hospitals should identify similar-sounding names and flag them in advance for clarification, the way an air-traffic controller will broadcast a warning that, say, American 55 and Northwest 65 are both in his sector. USP has a few other recommendations, according to vice president Diane Cousins, including "Tall-man" labeling that highlights the differences between similar names (acetaZOLamide for glaucoma, acetoHEXamid for diabetes), and "indication of use" labels, which can be as simple as "diabetes" or "antibiotic"--a quick backstop that patients themselves could make use of. Being in the hospital is scary enough without having to worry that you'll be getting a tranquilizer for your pneumonia.

© 2008