Prescriptions Fraught With Danger

Pittsburgh Post-Gazette (PA) October 25, 1993 Section: NATIONAL Edition: SOONER Page: A-1 Memo: MEDICATION ERRORS Day 2: HOW ERRORS HAPPEN

Steve Twedt, Post-Gazette Staff Writer

On a sunny April afternoon last year, 150 Western Pennsylvania hospital nurses, pharmacists and quality control specialists sat shoulder-to-shoulder in a Greentree Marriott meeting room for a seminar on avoiding medication errors.

One of the speakers, pharmacist Michael R. Cohen, polled them on a single question: How many had been stopped from making a medication error because the patient spoke up?

More than half raised their hands.

Those hands are testimony to the potential for disaster in America's hospitals, where millions of medications are dispensed daily by medical personnel who are often working under extraordinary pressure.

Despite chronic shortages, hospitals have been eliminating or freezing staff positions until they see the impact of national health care reforms, says the American Nurses Association.

And since the way hospitals are reimbursed by Medicare was overhauled 10 years ago, hospital personnel have been under constant pressure to treat patients and discharge them quickly, to maximize the money the hospital receives.

In addition, there are more drugs than ever. Hospital pharmacies may deal with 30 or so new drugs approved by the U.S. Food and Drug Administration each year, all of which may get thrown onto the mountain of some 2,300 generic and brand name medicines of varying strengths already available in most hospital pharmacies.

Doctors and nurses also now have the medicine, training and equipment to alter critical body functions in seconds. A drug once delivered in pill form might now be pushed directly into the patient's bloodstream.

"The danger is increasing," said medication errors expert Kenneth N. Barker, "because the medications are more likely to be intravenous medications and they're more likely to be drugs whose dosage limits are narrow and whose toxicity is greater." Errors creep into the medication delivery process from the moment a physician decides which medication to order and writes a prescription.

A study of the 289,411 prescriptions written at Albany Medical Center in 1987 detected 522 "significant" errors, 182 of them capable of causing death or serious injury. And even the most commonplace substances can prove fatal if overprescribed or delivered in the wrong way.

At Children's Hospital this summer, 3-year-old transplant recipient Zackery Gutierrez died from two tablespoons of common table salt in his feeding tube. The order had been written by a physician's assistant, and cosigned by a transplant surgeon who later said he had not read it.

With so many opportunities for catastrophe, vigilance is crucial. Pat DeLaPointe, pharmacist at the 175-bed Mesabi Regional Medical Center in Hibbing, Minn., said that a few years ago a new anesthesiologist there began using intrathecal Marcaine, an anesthetic injected directly into the spine. But the hospital also stocked another form of Marcaine, meant for intravenous injection, which contained a preservative. If mistakenly injected into a patient's spine, it could kill. "It strikes fear in your heart," DeLaPointe said. "You think, 'What if someone stepped up and put this in that port?' " Hospital officials switched brands on one of the drugs, believing that the different packaging would reduce chances of a mix-up.

Scribbled in Haste

While a patient may be diagnosed using a $2 million MRI scanner, the process of getting that patient the right medication in the right dose may start with a 29-cent Bic pen in the hand of a harried physician. "The medical record is probably the last bastion of handwritten documents in America," said medication error expert Neil M. Davis, co-founder with Michael R. Cohen of the Institute for Safe Medication Practices, Inc.

"If you got a handwritten document from your lawyer, you'd get a new lawyer." R. David Anderson, retired Virginia pharmacist and 1971-72 president of the American Society of Hospital Pharmacists, remembers suggesting in an address before the Augusta, Va., Medical Society that doctors at least be required to use block letters. That was in 1955. Three years ago, he was still pushing a similar proposal at the five-year meeting of the U.S. Pharmacopeia in Rockville, Md.

"We've been talking about this issue long enough," said Anderson. "It's time to do something about it." The poor quality of physicians' handwriting is more than just a humorous stereotype. In November 1979, the Journal of the American Medical Association published a study of 47 staff physicians at an unnamed 500-bed teaching hospital. It found that 16 percent of the physicians had illegible writing and that of another 17 percent was barely legible.

"Somehow (poor handwriting) has become fashionable, that the more you scrawl the more astute you are in your clinical abilities," said Dr. Bruce W. Dixon, director of the Allegheny County Health Department and member of the University of Pittsburgh School of Medicine faculty.

Some question whether the importance of clear prescription orders is given enough weight in American medical schools. Dixon noted that prescription writing is generally taught as a single one- hour pharmacology lecture during the second year of Pitt's medical school.

"But I'm not sure anyone really teaches them how to write prescriptions until they are interns per se, and by then their habits are pretty well established." Retired pharmacist Anderson said: "They (doctors) figure, 'Once I write the order and if you make a mistake, that's your problem, not mine.' " And it's not just a doctor's penmanship that's at issue. Others, including nurses, pharmacists and clerks, sometimes copy the doctor's original orders onto additional forms, each time risking writing an error into the prescription.

The problem was illustrated in a 1990 error at Montefiore Hospital that killed a 55-year-old woman. The woman was supposed to get two 5-milligram tablets of the potent cancer- fighting drug methotrexate one day each week.

The order, however, was written for 50-milligram tablets, a mistake which was caught. But in rewriting the order, the "one day each week" portion was omitted.

The woman died after receiving two methotrexate tablets each day for seven consecutive days.

Script for Disaster

The Post-Gazette's investigation of medication errors found numerous other tragedies that spotlight the hazards of handwritten orders:

-- The Kansas Board of Nursing received separate reports in February and March of 1992 of Tegretol, a potent anti-convulsant, being confused with Trental, which dilates blood vessels to improve blood flow. Charlene Shibel, a board investigator at the time, said: "The spelling is similar and if the physician wrote it out very sloppily sometimes it just gets transcribed wrong."

-- In October 1991, a South Carolina LPN read a doctor's order as calling for 5 milligrams of Ativan, a tension reliever, instead of .5 (one-half) milligrams. After the nurse administered five 1 milligram tablets, the 74-year-old patient had to be placed on a ventilator.

-- During a 12-month period in 1990-91, the University of Michigan in Ann Arbor had two separate mix-ups when doctors abbreviated orders for norfloxacin, an antibiotic, to "norflox." In both cases, the patients received Norflex, a muscle relaxant. One of the patients "was close to psychotic" before the error was discovered, said rheumatologist Dr. Robert Ike. Alarmed, Ike surveyed 41 staff physicians and learned that 19 used the ''norflox" abbreviation. "Until the two cases occurred close enough to get to recognize there was a problem, we didn't think of taking any action at all."

-- In December 1990, physicians with the California Parkinson's Foundation in San Jose reported that two Parkinson's patients in six months were given Stelazine, a treatment for anxiety which can induce Parkinson's, instead of selegiline, which slows it.

Their Parkinson's symptoms worsened, but both patients recovered when the Stelazine was stopped.

Dr. Matthias C. Kurth wrote in The New England Journal of Medicine ty of the led to these inadvertent misdispensations." Compounding the handwriting that can turn a medication order into a confusing alphabet soup.

Medication error experts Cohen and Davis have targeted doctors' abbreviation of "u" for "unit" because it so often looks like an extra zero, causing a ten-fold overdose. If the medicine is insulin, for instance, the result can be death.But many doctors use easily misinterpreted abbreviations every day, particularly in specifying dosages.

Among the commonly used Latin abbreviations, and English interpretations: q.i.d. (quater in die) for four times a day; q.d. (quaque die) for once daily; q.o.d. for every other day and q.o.h. for every other hour. A sloppy period in q.d. orders can make it look like an "i", Cohen and Davis, and such a mix-up has resulted in four-fold overdoses. Dixon said he tells University of Pittsburgh medical students to write out ''4x day," "daily," and "every other day." But he acknowledged the Latin abbreviations are a tradition of medicine that won't disappear quickly.

Preparation Mistakes

Breaking the usual calm efficiency of hospital pharmacies are sharp debates over the training of pharmacy technicians. Technicians, who usually need only a high school diploma, are directly involved in the preparation, labeling, and dispensing of some medications under a pharmacist's supervision.

This summer at the Veterans Affairs Medical Center in Omaha, the medical staff was alarmed and baffled when five patients "coded," or stopped breathing, within a 7 1/2-hour period. Ordinarily, the hospital would see about seven such incidents a month.

The mystery continued for three days until it was discovered that a pharmacy technician had put an antibiotic label on what was actually a potent paralyzing drug. And, to compound the error, he had covered the manufacturer's warning statement with the label. Two of the four patients who mistakenly received that drug died. Questions also have been raised about who should be granted access to the pharmacy and about the basic setup of the pharmacy itself. Pharmacies are being hard hit like costs, according to officials of the American Society of Hospital Pharmacists. And those cuts mean the workload for remaining staff has gone up, increasing the chances for slip-ups.

Pharmacist Cohen particularly worries about hospitals that shut down their pharmacies at night to save money. The hospital pharmacy -- most frequently at small, rural hospitals -- will close at 7 or 8 p.m. and "then the de facto pharmacist becomes the supervising nurse," he said. "We've placed them in an environment where they are just not equipped to handle some of the things they are forced to handle," he told his colleagues at the March mid-year meeting of the Pennsylvania Society of Hospital Pharmacists at the Downtown Westin William Penn.

"We've had some terrible accidents as a result." Still others say errors may have more to do with the alphabet than education and training. Pharmacies typically stock drugs in small bins, which are stored on shelves in alphabetical order.

That makes finding a drug quicker and easier. But it also means that Pitocin, packaged in a small ampule and given to pregnant women to induce labor, may be next to Pitressin, in the same-sized ampule, which causes the body to retain fluids and can raise blood pressure. That, in turn, could endanger an unborn child if mistakenly given to an expectant mother.

James E. Dice, director of pharmacy at Children's Hospital, recently found that his pharmacy stocked Aramine, which increases blood pressure, next to AquaMephyton, which helps blood clotting. The two were manufactured by the same pharmaceutical company and were packaged in almost identical boxes. If a child with bleeding problems got the drug that drove up bloodpressure, the results could be fatal. Once taken out of their boxes, the two bottles are distinctive. But, Dice said, an inexperienced nurse might not know of the differences. Inexperience isn't the only reason for medication errors, though. Anyone who has bought batteries, then realized at home they picked up AAA's instead of AA's, knows how mistakes slip in when a task becomes too routine.

"It's the problem of being overly familiar with what you're doing, of operating on an automatic level," said Marion Slack, an assistant research scientist at the University of Arizona in Tucson who has studied medication errors for about 10 years. "When you perform on automatic, a lot of information that is available is not processed. That's what allows the person to select the wrong bottle off the shelf and then dispense it."

Errors and Accidents

Some of the dispensing errors examined during the Post-Gazette's investigation demonstrate how frighteningly easy it is for them to occur:

-- The August 1992 Primary Care Medicine Drug Alerts reported that similar appearance of the tablets "may have been responsible" for a dispensing error in which 5 milligram tablets of DiaBeta, a diabetes medication, were given to a 63-year-old woman instead of the prescribed 1 milligram tablets of lorazepam, a depressant. The mistake was caught two days after the woman began acting confused and agitated.

-- On March 25, 1992, Muriel G. "Penny" Simons, 64, died in Crouse Irving Memorial Hospital in Syracuse, N.Y. after a pharmacy mix-up resulted in her getting the cancer-fighting drug cisplatin, or Platinol, instead of the prescribed -- and similar-sounding -- carboplatin, or Paraplatin.

-- Five-month-old Jacqueline Kaiser died March 31, 1991 at Minneapolis, Minn., Children's Medical Center after a pharmacy technician put nearly 40 times too much potassium chloride in a mix of protein and dextrose water. Two babies, both less than 2 months old, died Feb. 15, 1991 at Parkland Memorial Hospital in Dallas, Texas, after a staff Pharmacist dispensed a too-high concentration of Amphotericin B solution, used to fight fungal infections.

-- In 1989, an infant with congenital heart problems died at Mercy Medical Center in Oshkosh, Wis., after she was given 0.17 milligrams of digoxin. A pharmacist's Hospital Pharmacists has supported a long-running prevention campaign on medication errors society cannot force hospitals to follow its guidelines. And there are factors beyond the control of the hospital pharmacy, many of which come into play the moment the patient's dose leaves the pharmacy and winds its way to the bedside table.

Last Checkpoint

As the person who typically hooks up the IV, injects the syringe, or hands over the pill, the nurse represents the last safeguard between the patient and a possibly fatal medication error. All the flaws in the drug delivery process -- poor handwriting, confusing drug names, complicated doses -- are handed over to the nurse who picks up the medicine and heads to the patient's room.

Yet, medication errors expert Cohen pointed out, no one in the drug delivery process is more subject to the distractions that can lead to errors. "Anybody you talk to will tell you nurses work under are a lot of interruptions," said Cohen. He also believes nurses are not adequately trained in the effects of different medications. "It's so hit and miss how they find out about their drugs now." Kansas has one of the more aggressive systems for tracking nursing errors that cause patient harm.

At the request of the Post-Gazette, the Kansas Board of Nursing compiled a one year listing of medication errors: From July 1991 through June 1992, the state board learned of 76 nursing medication errors. These included 30 cases involving wrong doses, 16 wrong medications, five in which drugs were given to the wrong patient, seven in which drugs were administered at the wrong rate and three in which drugs were given by the wrong route.Again and againThe Post Gazette found the kinds of nurses' errors identified by Kansas all around the country.

Among them:

-- On March 7, 1990, a nurse mistakenly gave a 7-week-old infant at St. Mary's Hospital in Richmond, Va., 4 milligrams of morphine intravenously, instead of the 4 milligrams of Demerol ordered. The morphine dose was 10 times the recommended amount. On April 22, 1989, a patient at Vista Hills Medical Center in El Paso died after a nurse accidentally injected Mylanta into an IV line. It was one of four different Texas hospitals between 1987 and 1992. In two cases, newly graduated nurses gave the injection. In the other two, the nurses had been licensed for less than a month. On April 7, 1989, a nurse working at Baroness Erlanger Hospital in Chattanooga, Tenn., mistakenly hung an IV bag containing the heart drug lidocaine instead of another clear fluid, sodium chloride. The patient died.

-- On Oct. 14, 1988, a nurse who rotated through different departments mistakenly administered 6 cubic centimeters (120 milligrams) of morphine sulphate instead of the ordered 6 milligrams to a patient in a Lincoln, Neb., hospital's oncology unit. The nurse later said she was unfamiliar with the drug. The patient died.

-- On June 19, 1985, a 7-day-old baby at Medical Center of Tarzana, Calif., was given 10 times the prescribed dose of the heart medication digoxin by a nurse and died. When a mistake causes a patient's injury or death, nurses sometimes leave the profession if they're not pushed out. But without some industry-ide attempt to analyze why the mistake happened, simple solutions that might prevent a recurrence somewhere else are never identified.

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