There has been no shortage of medication errors in the news of late; at Indianapolis’ Methodist Hospital alone, medication errors have lead to the deaths of three infants and, just weeks later, the partial paralysis of a new mother. The infants received adult heparin injections — nearly 1,000 times the intended dose — and an improperly programmed pump delivered 10 hours’ worth of a painkiller in just one hour to the mother during childbirth.

Although no system — even an automated one — is perfect, technology could have prevented these tragedies. Bar coded medication administration, if properly performed, could have caught the adult heparin doses before they were given to the infants. In the case of the painkiller overdose, an intelligent infusion pump – or “smart” pump – could have alerted the clinician that the programmed infusion rate was beyond limits.

In reference to the infant deaths, Michael Cohen, president of ISMP, recently told PP&P, “Other than providing neonatal nurses with pharmacyor manufacturer-prepared heparin in the exact amount needed for umbilical line flushes, I think one of the most promising safety strategies...to prevent this type of event has to be bar code scanning each and every drug package dispensed by pharmacy. Further, this should extend to scanning each dose at the patient’s side.” Cohen further encouraged us to read up on a recent study, published in the Annals of Internal Medicine, which indicates a significant reduction in error potential via bar coded medication dispensing and administration. (www.annals.org/cgi/content/ abstract/145/6/426)

We at PP&P urge you, if you aren’t already, to take a serious look at the technology available to health care practitioners for preventing these kinds of tragic errors, in addition to reviewing your current medication dispensing and administration processes. Serious medication errors must be prevented and can be significantly reduced by the implementation of automation, in conjunction with conscientious processes and procedures for patient care.
With that said, we send our most heartfelt condolences to those affected by the recent events at Methodist Hospital.

All the best,

R. Mitchell Halvorsen