Almost four years ago, a report by the Institute of Medicine made headlines by calling attention to the need to address medical errors in the U.S. healthcare system. The report found that between 44,000 people and 98,000 people die in hospitals each year as a result of preventable medical errors. The issue is no less critical today, especially when one considers the highly publicized incident in February when a 17-year-old girl died two weeks after she mistakenly received organs with a different blood type during a heart-lung transplant operation at Duke University Hospital.
Deaths from medication errors that take place both in and out of hospitals — more than 7,000 annually — alone exceed those from workplace injuries, according to the IOM report. The majority of medical errors do not result from individual recklessness, the IOM report found, but from basic flaws in the way the health system is organized. Stocking patient-care units in hospitals, for example, with certain full-strength drugs — even though they are toxic unless diluted — has resulted in deadly mistakes. And illegible writing in medical records has resulted in administration of a drug for which the patient has a known allergy.
Four years ago, the report’s recommendation was that hospitals and healthcare organizations should implement proven medication safety practices, such as using automated drug-ordering and bar-coding systems.
The Food and Drug Administration also has recognized this critical situation, and as this issue went to press, issued a proposed requirement for bar codes on all pharmaceutical products, excluding samples, to reduce the number of medication…
Drug Error Reporting
Barriers to Bar Coding
Experts on this Topic
Louise Baran. Marketing Manager, Nursing, B. Braun Medical Inc., Bethlehem, Pa.; B. Braun is a full-line supplier of healthcare products and programs designed to improve both patient and clinician safety. For more information, visit bbraunusa.com.
John R. Combes, M.D. Chairperson, National Coordinating Council for Medication Error Reporting and Prevention, and Senior Medical Advisor, The Hospital & Healthsystem Association of Pennsylvania, Harrisburg, Pa.; HAP is a statewide membership services organization that advocates for nearly 250 Pennsylvania acute and specialty care, primary-care, subacute care, long-term care, home health, and hospice providers, as well as the patients and communities they serve. For more information, visit haponline.org.
Richard Hollander. Senior Director/Team Leader of packaging services and global manufacturing, Pfizer Inc., New York; Pfizer discovers, develops, manufactures, and markets leading prescription medicines for humans and animals and many of the world’s best-known consumer brands. For more information, visit pfizer.com.
John H. Riddick. Director, QA/RA and Supplier Certification, Novation LLC; Irving, Texas; Novation is a leading supply-chain management company in the healthcare industry, serving the more than 2,400 members of VHA Inc. and the University HealthSystem Consortium. For more information, visit novationco.com.
Dan Thomas. Director, Information Technology, RxCrossroads and MDI, Louisville, Ky.; RxCrossroads is a healthcare products commercialization support company, providing services that range from pre-launch tactical consulting to implementation and management of complex reimbursement, as well as distribution-support programs. For more information, visit rxcrossroads.com.
Kasey K. Thompson, Pharm.D. Director, Center on Patient Safety, American Society of Health-System Pharmacists, Bethesda, Md.; ASHP is the 30,000-member national professional association that represents pharmacists who practice in hospitals, health
maintenance organizations, long-term care facilities, home care, and other components of healthcare systems. For
more information, visit ashp.org.
John F. Tourville, Pharm.D. Department Director, Pharmacy, Children’s Medical Center of Dallas, Dallas; Children’s Medical Center is a private, not-for-profit institution. The Center is the only Dallas healthcare facility that deals exclusively with a variety of diseases and disorders among children from birth to age 18. For more information, visit childrens.com.