Mistakes happen. That’s because humans are not infallible. People write illegibly or mumble unintelligibly. This leads to “little” errors, like mistaking one drug for another.
Pharmacists tell us that the heartburn and ulcer drug Zantac can easily be confused with the sound-alike anti-anxiety agent Xanax. Sometimes the wrong drug is dispensed. Dosing errors occur because someone misplaces a decimal point.
Mistakes Can Be Lethal:
It was just such a clerical error that led to the high-profile tragic death of Mexican teenager Jesica Santillan. She received a heart and lung transplant from a donor with type A blood. Jesica herself had incompatible type O blood. The resulting rejection led to her death.
This medical mistake made headlines all around the world. But every day in hospitals and pharmacies other people are at risk of equally deadly errors. Most go unrecognized and unreported.
My Mother Died At the Same Hospital:
Helen Graedon went into the hospital for a routine angioplasty. The doctors administered a blood-thinning drug to prevent clotting after the procedure. They overlooked the fact that my mother had experienced a bleeding episode a week earlier, making this drug far too dangerous. In addition, a resident administered a pain reliever called Demerol, which interacted dangerously with another medication she was on. The combination led serotonin syndrome. Symptoms included uncontrollable muscle spasms, which in turn led to internal bleeding. My mom died the next day.
Preventing Avoidable Mistakes:
Hospitals have begun to recognize that individual doctors or nurses cannot always catch every mistake. Fail-safe systems must be implemented to protect patients from human error.
Jesica’s tragic death led one leading transplant doctor to conclude that there should be lots of “back checks and double checks and rechecks.”
Until such systems are implemented, patients should have friends or family members with them at all times throughout a hospitalization. With nursing shortages as severe as they currently are, it may even be necessary to hire a private nurse to oversee the patient’s hospital care. Although this is expensive, it could save the patient’s life.
Preventing Pharmacy Errors:
In the pharmacy the same level of vigilance is necessary. Pharmacists are almost as scarce and overworked as nurses. A study revealed that as many as two mistakes may be made for every 100 prescriptions dispensed. One expert, Dr. Elizabeth Flynn, estimated that “this translates to over 60 million errors on 3 billion prescriptions filled each year in the US.”
Whenever you or someone you love receives a prescription, make sure it is printed legibly with instructions in English, not Latin code. Keep a photocopy of the prescription so you can double check the information on the bottle when you get your medicine.
It is also important to take pills correctly and avoid life-threatening interactions. To help you in this process we have created a Drug Safety Questionnaire and Medical History. It is free to download.
You will also want to listen to our FREE podcast “Surviving Medical Errors and Seeking the Truth.”
It’s not possible to eliminate all errors. But it is imperative that we catch as many as possible before another unlucky person dies like Jesica Santillan or my mother, Helen Graedon.
Share your own story below in the comment section.
Revised: 6/15/17
