Deadly Drug Disasters Are Preventable

Every day in this country someone dies from a medication mistake. According to the FDA, more than one million people are injured annually because of drug errors.
In some cases a patient gets the wrong medicine from the pharmacy. Other times it is the wrong dose. In the hospital, a patient may be given an intravenous solution (abbreviated IV) instead of a medicine dose in international units (abbreviated IU).
There are many reasons for such errors. People may mis-read or mis-hear drug names. For example, the anti-seizure drug Lamictal could be easily confused with the antifungal medicine Lamisil. Over the phone the anti-anxiety agent Xanax sounds a lot like the acid suppressor Zantac.
That is why physicians, pharmacists and nurses should pay attention to airline pilots and air traffic controllers. They have developed checklists and techniques for reducing misunderstandings.
To avoid confusion with letters that might sound alike such as F and S, pilots use the words Foxtrot for F and Sierra for S. B and V are easy to mix up, so pilots use the words Bravo and Victor.
Perhaps it is time for health care to borrow a page or two from aviation. Setting up systems to catch errors before they harm patients is a good idea.
Drug safety experts have come up with a recommendation to emphasize the differences between drug names. They suggest using “tall man letters” to make the distinctions stand out. This means capitalizing the most distinct parts of a similar pair. This would cover drugs such as buPROPion (an antidepressant) and busPIRone (an anti-anxiety drug), or the heartburn medicine PriLOSEC and the antidepressant PROzac.
Many hospitals are turning to barcodes to make sure that the drug the doctor orders is given to the correct patient. Both the medicine container and the patient have barcodes. The patient wears the barcode on a plastic ID bracelet.
Nobody has a higher stake in avoiding medication errors than the patient, so it is time patients became part of the health care team. Along with doctors, nurses and dietitians, patients should be double-checking everything they are given in the hospital.
If they are not familiar with a drug the nurse brings, they should ask who ordered it and why. If a person on a low-sodium diet is served three slices of bacon with breakfast, that doesn’t mean it is okay to ignore the diet and enjoy the salty bacon. When patients are too sick to pay attention and stand up for themselves, a family member or friend should be advocating for them.
Outside the hospital there are other measures that can help against medication mishaps.
* Do not request that your doctor phone or fax in a prescription. The time you think you may save is not worth the risk.
* Always get a photocopy of your prescription so you can double-check your pill bottle with the original prescription.
* Make sure you can read the prescription. It should be typed or printed in English. No Latin abbreviations or scribbles should be accepted.
With medication mistakes so common and so dangerous, it is crucial for patients and their families to be vigilant. Health care professionals should welcome patients as a vital part of the health care team.