Tue Dec 9,10:53 AM ET
By JANET McCONNAUGHEY, Associated Press Writer
NEW ORLEANS - Despite years of warnings, the same drugs continue to top medication error lists, a nonprofit group says.
Insulin, morphine, two blood thinners and potassium chloride all of them "high-alert medications" made up five of the top six drugs involved in errors reported last year to United States Pharmacopeia. Those five drugs are among those most likely to cause harm when used incorrectly. Doctors, nurses and pharmacists know this.
Still, the drugs were involved in more than 19,500 of nearly 192,500 medication errors reported voluntarily and anonymously to USP, which works with government, industry and health professions to set drug purity and quality standards, Diane D. Cousins said.
Because the reporting system is voluntary the figures may be low, said Cousins, vice president of USP's Center for the Advancement of Patient Safety. "We should be cautious of concluding this is an accurate picture of medical error nationwide," she said.
The five drugs all are potent medicines for common problems but ones for which the "window of safety" is small, said Dr. Michael D. Fetters of the University of Michigan, who was not involved in the study.
Fetters, an assistant professor of family medicine at the University of Michigan whose area of expertise is errors in primary care, said they also are drugs which have no safer alternatives.
"The only way to reduce these errors is to increase the numbers of checks and balances in the system," he said. He said those include computerized office systems and more checks by pharmacists.
Anyone who might be involved with any of the drugs including patients and their families as well as nurses, pharmacists and medical assistants should be "empowered to stop the process and ask questions," he said. "These are the big picture answers, and they're the hardest."
All told, Cousins said, the errors reported to USP last year involved 1,400 products, up from 1,100 in 2001.
"There has been little variation overall in products involved in harmful errors," she said, and mistakes were made for all dosage forms and strengths of each drug.
Most of the 192,500 errors did not cause any harm, but 3,193 1.7 percent did. Twenty were fatal. The drugs which showed up most often in harmful errors all affected the central nervous system: narcotic painkillers; sedatives, hypnotics and anti-anxiety drugs; and anticonvulsants. They accounted for 749 of the harmful errors.
Looking at such classes of drugs may be a useful way to help prevent medical errors, said Dr. Paul M. Schyve (pronounced SHY'-vee), senior vice present of the Joint Commission for Accreditation of Health Organizations.
He participated by phone in a news conference with Cousins, who presented the data at the American Society of Health-System Pharmacists (news - web sites)' mid-year meeting in New Orleans.
The 5,862 incidents involving liquid albuterol, misted into breathing machines for respiratory therapy, topped the drug list.
"Those were almost exclusively omission errors ... A dose was not given when it should have been," Cousins said.
Hospitals likely were on the lookout for such mistakes because the accreditation commission had found that many patients don't get scheduled doses of drugs for respiratory therapy, she said. Since the commission is looking at that area, hospitals have been keeping track of such errors so they can answer its questions, she said.
Insulin was involved in 5,583 errors, morphine in 3,919, potassium chloride in 3,771, and the blood thinners heparin in 3,684 and warfarin in 2,564.
Cousins said the number of health organizations participating in its "Medmarx" surveys rose 31 percent between 2001 and 2002, to 482, while the number of incients rose 82 percent. That increase is because more errors are found and reported, rather than because more are occurring, she said.
Schyve said the joint commission's goals include keeping undiluted potassium chloride and other electrolytes out of patient care units, and limiting the number of concentrations at which drugs are used.
Undiluted potassium chloride is lethal. Since it is always diluted before use, that should be done before it is brought to a patient care unit, he said.
And, he said, people get used to working with specific concentrations of drugs. The more concentrations are available, the more likely that each patient's dose must be calculated, and the more likely mistakes are.
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