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When a medication error occurs during a hospitalization it is likely there are multiple causes. It is also likely the hospital will not undertake the proper analysis of the error to correct the hospital processes involved. That is the gist of an article posted by Emily DeVoto, Ph.D., who is an independent health care consultant and epidemiologist. Emily is definitely independent based upon these strong and helpful words.

Tunnel vision and patient safety

An unsigned article from yesterday’s AP wire, about a woman who was temporarily paralyzed from too rapid administration of a painkiller during childbirth, made me sad. Sad for the unfortunate patient, yes, but sadder still for the country’s collective (mis)understanding of how such incidents really happen and, thus, what it takes to prevent them.

Apparently the pump that delivers an epidural medication was misprogrammed, and the patient received 10 times the amount she should have over one hour (she recovered, and her baby was fine).

The article states that the hospital referred to the incident as a “doctor’s mistake” – and the hospital’s statement, not the putative mistake, to my mind, should have been the story. Clearly they were trying to shift the blame, but what does assigning blame do for you (the hospital that is) when what you really should be doing is getting busy figuring how this and [a] previous, more serious, incident [involving deaths] happened in the first place? That means examining assiduously all of the hospital processes that take place in order for medication to get inside a patient: how medication orders are filled, the installation of the pump, instructions for operating it, how health care workers are trained to use the pump, procedures for double-checking dosages and drug names, etc., etc.

It also means that you have to have data on adverse events and close calls, collected in a way that promotes understanding and facilitates prevention, and – this is the scary part for hospitals – in a non-punitive fashion. Of course, there are truly negligent practitioners out there, but the current system targets those who happen to be at the sharp end of the needle, as it were, when an error occurs.

I can add my conclusion after handling medication error cases for over 35 years in Florida – the individual medication error can almost always be traced to lax policies and procedures or a customary failure to follow the policies and procedures. It is when the norm is unsafe that the error eventually causes a tragedy. Malpractice in the administration of medications in hospitals is often more pervasive than a single isolated mistake by a doctor or nurse.

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