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