Module 1 – Unit 7: Exploring the Topic
Avoiding Medical Errors
Think About It Do you think errors are common occurrences in health care settings? What types of errors do you think are the most common? How could the errors below have been avoided?
Intern doctor mistakenly injects patient with olive oil instead of antibiotics
A medical intern at a hospital in western Austria mistakenly injected an elderly patient with olive oil instead of antibiotics after mixing up bedside vials. The mix-up apparently happened when the intern reached for the wrong vial and injected the patient with olive oil that had been prepared by a hospital physiotherapist for a massage.
Adapted from: San Francisco Chronicle. http://sfgate.com. Retrieved 10/9/04.
The right medication in the wrong place
After treating a patient’s earache, a doctor wrote a prescription; next to the medication and dosage, he wrote, ‘R ear.’ The nurse didn’t realize that this meant ‘right ear’ and so, with the patient’s consent, administered the medication in the rear.
Source: Langer, E.J. Psychology Today. Please pass the role. http://cms.psychologytoday.com/articles. Retrieved 9/19/04.
Medication error attributed to poor handwriting
Medication errors occur for a wide variety of reasons. One of the most prevalent causes is illegible handwriting. In a report received through the MER Program, poor handwriting was identified as the cause of a medication error that resulted in a diabetic patient receiving the wrong type of insulin. The pharmacist interpreted the word "Lantus" as "Lente". As a result, Lente® Iletin® II insulin was dispensed from the pharmacy. The patient received one dose of the Lente insulin before the error was discovered.
Adapted from: The United States Pharmacopeial Convention, Inc. http://www.usp.org/. Retrieved 3/22/05.
Drug confusion is fatal for teenager
A 16-year-old patient was recovering at an extremely busy, understaffed hospital from a chest injury sustained while riding his skateboard. The physician in the ED ordered morphine 10 mg IV for pain, but the nurse mistakenly selected hydromorphone. Both drugs were stocked in the same area in 1-mg/mL and 10-mg/mL ampules. As a result, the patient received the 10 mg hydromorphone—the equivalent of 50 mg to 60 mg of morphine. The error was not discovered until after the patient arrested and died from the first IV dose.
Source: Nursing Center. http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=574053. Retrieved 03/29/05.
What are other health care errors you have witnessed or heard about? What are the possible consequences of medical errors for patients? For health professionals?