My heart broke that day in November of 2007, when I read the story about the medication error that nearly took the lives of the infant twins of the movie star Dennis Quaid and his wife Kimberly. I was devastated that an overdose of a potent blood thinner had been administered to those two babies. At the same time, I felt a great sense of personal frustration and pain. I am a Pharmacist who has devoted my thirty year career in healthcare to preventing medical mistakes.
What most people don't know is that this exact same mistake had occurred in an Indianapolis hospital one year earlier. This time six babies were given the overdose. Three babies lived, and three babies died.
That's not the end of the story. In July of 2008 (one and one-half years after the Quaid overdose) the same error happened again in a Texas hospital. Fourteen babies were given the same drug overdose. Two twin premature babies died as a result of the same mistake.
Enough is enough.
In 1999 the Institute of Medicine (IOM) published a report which stated that nearly 98,000 people die needlessly each year because of medical mistakes. In 2009 the Consumers Union published a follow up to the IOM report basically stating that absolutely nothing had changed in the past ten years. The Consumers Union concluded that "There is little evidence to suggest that the number of people dying from medical harm has dropped since the IOM first warned about these deadly mistakes a decade ago." The Consumers Union projects that preventable, medical mistakes account for more than 100,000 deaths each year- or as many as one million lives over the past decade.
As a Pharmacist who has cared for thousands of patients over the past 3 decades, I have also investigated thousands of medication errors. I have led countless teams of healthcare professionals through the process of analyzing why the errors have occurred. I have provided oversight for medical professionals throughout hospitals, nursing homes and HMOs in an attempt to get to the root-cause of serious events. I have reviewed errors in small private community hospitals, small rural hospitals, large teaching hospitals and government institutions. These errors have happened to people regardless of age, gender, race, income, education, or social status. If a potentially fatal medication error can happen to the newborn babies of a movie star, they can happen to you.
In my personal experience, I have yet to find one person who does not know someone or who has not experienced a medical mistake. I have heard stories about parents being given the wrong drug, siblings getting a drug meant for someone else, children getting the wrong dose, spouses getting drugs that they are allergic to, friends taking two drugs that interact with each other and acquaintances taking the drug in the wrong way. The mistakes that I have heard about would fill volumes. All of these people have endured a tremendous amount of personal pain and expense because of preventable and needless medication mistakes. This is a sad reality, but a reality nonetheless.
Preventing medication errors and improving efficiency is a main focus of the healthcare reform plan. Not only will reducing medication errors improve the quality of patient care it will also provide a significant cost savings to our nation.
There is one key element that continues to be overlooked in the prevention of medication errors and that is the patient himself.
The focus of medication error prevention should now include the empowerment of the patient by providing the tools necessary to conduct effective and complete dialog with their doctors and other healthcare providers. Healthcare consumers (and the people who care for them) must realize the importance of taking responsibility for their own healthcare and take action to prevent a medical mistake from happening to them.
Mary Sue McAslan, Pharm.D.
America's Family Pharmacist
DrMarySue@americasfamilypharmacist.com
http://www.americasfamilypharmacist.com
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