HEALTH

You Say Aspirin, I Say Heparin

A rising number of medical errors are due to drug-name confusion. What can be done, and why a former Navy pilot is offering doctors some accuracy tips.

By Jerry Adler | Newsweek Web Exclusive

Jan 30, 2008

« Return to Article

Discuss

Posted By: CAndrews8 @ 02/12/2008 11:32:45 PM

Comment: As a second year pharmacy student at the University of Pittsburgh, it saddens me that no one has addressed the role of the pharmacist in any of this discussion. There's an entire profession devoted to knowing the difference of the names of medications and the significance of those differences. I agree that more standardized protocol is necessary and some handwriting is terrible, but if our society would allow a paradigm shift in the pharmacist's responsibilities, maybe we could move from behind the counter (or in the basement of the hospital) and onto the floor as an active advocate for medication safety. Or what if, instead of going to the pharmacy and demanding your prescription (along with any solved insurance problems) in five minutes, you actually expected to SIT and TALK with the PHARMACIST about your medication and how to manage it. This would help identify, resolve, and prevent a plethora of medication errors both on behalf of the healthcare professionals that prescribe and dispense, and the patients that adhere to their medication regimens.
Posted By: Girl_in_Alaska @ 02/12/2008 11:27:27 PM

Comment: As a current nursing student I can say that Pharmacology class and early stringent requirements to follow the 5 rights of medication administration are being firmly drilled into my head. This does not make me feel any better about the prospect of causing a medication error. This is the one of the aspects of nursing that keeps me awake at night as it should. I have difficulty reading Physicians orders for care as well as medication, and couldn't agree with blackfordgrad enough........thank you Unit Clerks!
Posted By: blackfordgrad @ 01/31/2008 11:13:38 PM

Comment: Thank God for Unit Clerks! The underpayed, overworked, translator. Time and time again, when the doctor's
writing is slopey and the meds ordered are not proper, or cannot be tolerated with other meds, it's the experienced unit clerks who call the doctors and correct the mistakes. When the patient needs immediate attention it once again the Unit Clerk who demands a RN beline to the patient. The nurse follows the orders and in rare occasions questions the doctors. It is also the patients right and responsibility to question everything. Ask,ask,ask, it's your right and duty. I have respect for all menical workers, especially in te hospital enviroment, but the unsung heros are the Unir Clerks.
Posted By: C. MacLean @ 01/30/2008 10:50:13 PM

Comment: "Checklists, written protocols, standardized scripts."
Why does Mr. Harden assume that these things aren't already in place? Clearly, he has not been in the hopitals I have worked in; they are full of checklists, written protocols and standardized scripts. The problem is that patients are not airplanes, and the art of medicine is not the same as the science of flying.

Nurses don't tell pilots how to fly - why should pilots tell nurses how to give medications?

If we really want to cut down on medication errors, we need to do two things: (a) ask the actual people who administer the medicines - the nurses - how to fix the problem and (b) educate doctors to understand that they prescribe much too much medication in the first place.

Most of the chronic disease we face today - heart disease, type II diabetes, asthma, addiction - can be controlled or cured by changing behavior. Teach a doctor to help patients achieve and maintain behavioral change, and the medicines will be obsolete.

Then we won't need pilots telling us how to fix medication errors.
Posted By: EE7011 @ 01/30/2008 4:26:51 PM

Comment: I would like to acknowledge the fact that for the most part, nurses and doctors do administer the correct medications to the correct patients. However, in the healthcare profession there is virtually no room for error. In nursing school students learn about the 5 Rs 1) The right patient 2) right medication 3) right dose 4) right route 5) right time and recently two more have been added 6) right documentation 7) right reason. Nurses have a huge responsibility when it comes to medication administration. Often times they are the last line of defense and need to be able to notice errors. If an administration error occurs be honest about it. It could save a patient's life. Understanding the names and purposes of medications comes with experience. If a nurse doesn't know what a medication is used for, for goodness sakes ASK. A nurse must guard their license at all times.
Posted By: dorasellshouses @ 01/30/2008 2:27:30 PM

Comment: Sorry Kolketamine that would not work due to even if you scream it, the people hearing it don't know the diagnosis therefore you could be screaming the name and it would not make any difference. one thing that could work though, it would be to have Doctors and Nurses memorize the meds. that;s what you are supposed to do. if the doctor asks for levothyroxine the nurse should know that is related to the thyroid. so she should ask the doc. you want thyroid med is that right?
Posted By: kolketamine @ 01/30/2008 1:11:52 PM

Comment: I have never been in a real like ER but another suggestion may be a simple callback system that is used in resteraunts. When a chef or expeditor calls a ticket out the line cooks will echo the callback making sure that everybody is on the same page. In the ER a doctor would call the drug out and the nurse who is supposed to deliver it would yell out what it is reinforcing the instructions. Simple and cheap.