Medication Errors: Behind closed doors
Medication errors seems to be a hot topic that is revived from time to time. Often it comes up in a slightly sensationalised form in the media, with grim statistics accompanying a photo of a busy hospital, and comments made on the negative outcomes for recipients of such errors.
Exactly how often do medication errors happen in hospitals?
Statistics paint pictures that make remarkable claims, yet it’s very difficult to validate or construct exact data on the frequency and severity of errors. For instance, according to The Australian, mistakes happen more frequently in Queensland than any other state or territory of Australia.
Delve a little deeper into that claim, however and you’ll find that they are only commenting on 187 deadly or damaging lapses in judgment or procedures that were made public, and working out which state had the most of those… So what they are referring to are situations like when patients have died through medication errors, had surgical instruments left in place or had the wrong blood transfused.
But what of your everyday, run of the mill mistake?
Whilte I’ve been fortunate enough to get by without making any mistakes in the last 10 years (that I know of!), I have been familiar with a few cases that happened in places I’ve worked, for instance:
- Someone drew up and gave 10 times the correct amount of short-acting insulin
- A nurse drew up suxamethonium and gave the syringe to another nurse who injected it, thinking it was metoclopramide
- Nurses drew up a massive amount of potassium to give to a patient in a short time frame according to the order where a new, junior doctor had calculated the doses wrong
- Water for injections is used as a flush instead of saline
Most of the errors I’ve come across or heard about have been due to either people working tired, understaffing, junior staff not picking up on erroneous medication dosages, momentary lapses in judgment or failure to follow procedures (ie two staff checking drugs etc).
While errors like these happen from time to time, I’m not so sure they happen quite as frequently as people might assume. Certainly long periods of time go by without any errors being made, and most errors are fairly minor, with little or no consequences.
I’d also like to mention that most errors I have seen have been swept under the rug. By this, I mean covered up, not mentioned to the hospital, or in some cases the order gets changed to reflect what was really given. I’ve seen instances where the patient has been told, but more commonly the patient is not. There has been a definite swing from how things used to be however; it’s easier to report situations now and the ramifications seem to not be as dire for staff involved.
In serious cases everything is made a little more public – the error gets reported to the hospital, goes on the patient’s file, the patient gets told, and disciplinary action goes ahead with the staff member if necessary. Often times however the hospital or greater management disagree with front line staff as to who is responsible and why mistakes have occurred.
How often do errors occur where you work? Is there a foolproof system that exists?!
