Healthcare News & Insights

Big medication errors happening in hospitals

Medication errors are still a significant problem in hospitals. While they’re supposed to be “never events,” they occur at an alarming rate every day – and patients can be seriously harmed as a result. 

pill-bottle-at-computerLast month, a research team from Massachusetts General Hospital published a study in the journal Anesthesiology suggesting that medication errors had the potential to occur in almost half of all surgeries.

According to an article from Bloomberg, the team observed over 270 of the procedures performed at Massachusetts General and noticed medication errors occurring at shocking rates.

Even worse: Over one-third of those errors hurt patients in some way, whether the mistake affected their vital signs or put them at increased risk of infection.

While no one died because of the surgical team’s medication mistakes, three patients were actually put in life-threatening situations.

Syringe mixup

This scenario plays out far too often at hospitals across the nation. In fact, one recent medication error at a Pennsylvania hospital put patients in “immediate jeopardy,” as stated by hospital officials.

An article in the Pittsburgh Tribune describes the mishap. Instead of the actual narcotic prescribed by their doctors, patients at Butler Memorial Hospital accidentally received injections of a drug that’s seven times more powerful.

The syringes administered to the patients were supposed to be filled with morphine sulfate. But a staffer put syringes filled with potent pain killer Dilaudid inside a storage dispenser instead. Eighteen patients were medicated with these syringes before the hospital discovered the problem.

Thankfully, no patients were hurt because of the error.

Confusing Dilaudid with morphine sulfate is a surprisingly common mistake in hospitals. Reason: The two drugs have similar generic names – morphine and hydromorphone.

In fact, according to Michael Cohen, president of the Institute for Safe Medication Practices (who was quoted in the Tribune’s article), some healthcare professionals don’t even realize there’s a difference between the two.

But the worst part about Butler Memorial’s mistake: There were two chances to make it right.

Initially, the staffer only placed 15 prefilled syringes with hydromorphone into the wrong container. A few minutes later, someone put three additional hydromorphone syringes in a different, incorrect container.

Separate groups of hospital clinical staff retrieved needles from each container – and not one person verified they contained the correct drug and dosage.

As a state inspection report about the safety violation stated: “The staff failed to ensure patient safety and meet the needs of patients” by not following proper medication safety protocol.

The hospital is currently following a corrective action plan to keep a mistake of this magnitude from happening again. It includes intensive retraining and monitoring to make sure safe medication dispensing practices don’t fall through the cracks.

Error prevention

Butler Memorial was lucky no patients were harmed. Other facilities can’t always say the same after such a significant medication error.

Since the stakes are so high, it’s crucial for hospitals to get medication dosage right the first time. Many facilities have cut down on errors by using bar-code technology to scan each drug before giving it to patients.

In addition, certain electronic health records (EHR) systems have built-in alerts if a patient’s prescribed a drug in error due to allergies or drug interaction issues.

But ultimately, clinical staff can’t go wrong by following Cohen’s classic advice: “We always tell people to read the label. Read the label.”

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