A Race to Change - Focus on Medication Safety

by Todd Karpinski, ICHP President
February 9, 2010

Having recently returned from the 2009 ASHP Midyear meeting, I find myself more focused on the importance of medication safety than ever before. I had the opportunity to attend the Opening Session given by charismatic actor Dennis Quaid (yes, the actor who played Jerry Lee Lewis in “Great Balls of Fire”!). Quaid spoke of the devastating events that his twins endured at Cedars-Sinai Medical Center in 2007. For those who may be unfamiliar with the story, each twin, Thomas Boone and Zoe Grace, received a 1000-fold overdose of heparin…twice. The twins received protamine treatments for 41 hours following the overdoses. Despite extensive internal bleeding and associated complications, the twins were released from the hospital 12 days following the medication errors and appear to have no residual negative effects from the event.

Some would say the Quaid twins were lucky; I suppose this may be true considering other infants across the country lost their lives due to a similar error. However, I have a hard time associating the word luck to a 1000-fold overdose of heparin. I would say the twins experienced a miraculous outcome to a very unlucky event – an event in which one twin received the overdose of heparin even after four, yes FOUR, nurses verified the dose. As unfathomable as this may seem to the general public, those of us in healthcare know this happens on a daily basis within each of our institutions. Most of these events do not result in harm and are generally not reported; however, each event has the potential to lead to significant harm and death.

During the session, Quaid did not place blame on the individual doctors, nurses, and pharmacists at Cedars-Sinai. Rather he focused his attention on the broken system in which health care professionals work. This system has become more and more obsessed with the threat of exposure to liability and protecting its bottom line rather than being vigilant about correcting the flaws in the system that are the root cause of that very exposure. Quaid concluded his session by discussing the Quaid Foundation’s mission to raise the standards of medical care by: 1. Breaking the conspiracy of silence, 2. Eliminating human error and 3. Enhancing patients’ rights. Quaid also discussed the programs occurring at the national level within pharmacy, including the ASHP Technician Training initiative and the use of barcode technology, as a step in the right direction to eliminate medication errors.

As I stated in the beginning, I am taking a renewed sense of urgency toward the elimination of medication errors back to my facility. Despite the fact that we have highly trained pharmacists and technicians and employ barcode scanning at most steps in the medication use process, we must do more to eliminate the potential for errors. We will be revamping our medication safety committee to include more physician engagement, to refocus on promoting a Just Culture within the organization and to elevate the reporting hierarchy of the committee.

I would encourage each of you to take a fresh look at medication safety within your organization. Do you truly have the non-punitive or Just Culture environment you seek? Are you prospectively examining your medication use processes to identify error points? Is medication safety a focus within your institution?

The Division of Professional Affairs will be placing a dedicated focus on providing tools and educational programming to help the membership with medication safety efforts. This group is comprised of medication safety experts, clinicians and administrative pharmacists from across the state. It is my hope that their work, and that of all pharmacists across the state and nation, will help bring us closer to an error-free health care environment.

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