Preventing Health Care Harm

According to the FDA, “Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States.”
Such statistics are too overwhelming to comprehend, so we tend to ignore, reject and deny them. Patients aren’t the only ones having a hard time wrapping their heads around these numbers. Healthcare providers are, too.
Why are medication mistakes so easy to make–and so hard to catch? Part of the problem has to do with the economy. Hospitals struggling to break even in a bad time may cut staff and reduce hours. Pharmacies worried about making ends meet hire more pharmacy techs and have fewer pharmacists supervising them. But all of this means everyone, from the doctor to the pharmacy tech, is in hurry-up mode and may not be double-checking the patient’s medicine as carefully as necessary.
Pharmacy technicians do essential work both in the hospital and in the community drugstore. But the training for this position varies widely. Some people may have degrees from a community college, while others may receive most of their training on the job. Yet these are the people who prepare that little bottle of pills you pick up from your neighborhood pharmacy. They may also be preparing medicines for administration by nurses in the community hospital.
A tragedy in Ohio has brought the responsibilities of pharmacy technicians to public attention. A little girl named Emily Jerry was being treated for cancer in Cleveland. She was almost ready for discharge, and her parents were planning to take her to Disney World to celebrate. Then she was given an injection that the pharmacy tech had prepared incorrectly, with 26 times more sodium in the saline solution than it should have had. The supervising pharmacist, feeling rushed, didn’t notice the mistake and the toddler died as a result.
Pharmacy technicians are not the only ones who can make deadly blunders, though. Pharmacists make mistakes too. According to one study, the average pharmacy incorrectly fills four prescriptions each day. This adds up to about 51.5 million errors annually (Journal of the American Pharmaceutical Association, March/April, 2003).
Doctors and nurses are not immune. Actor Dennis Quaid’s newborn twins were administered a whopping overdose of the blood thinning drug heparin and nearly died. Now he is a vocal advocate for reducing healthcare harm.
Everyone needs to recognize that errors are common, but many can be prevented. Patients play a crucial role in this process.
Next time you pick up a prescription at your local pharmacy, don’t just grab your bag of pills and rush out the door. Stop right there at the counter and check to make sure the pills you received are the ones your doctor prescribed. To do that, it helps to keep a photocopy of your original prescription. Check the name, the dose and the instructions.
Before you leave the drugstore ask to speak with the pharmacist. Find out exactly how to swallow your pills (with meals or on an empty stomach), what the most common side effects are and what the most dangerous complications could be. To help you with this conversation we offer our free Drug Safety Questionnaire.