Medical errors are a common occurrence in the healthcare industry. Medical errors arise due to the prescription of a wrong medication or administration of a wrong dose of a drug. Pharmacies have the obligation to administer the right prescriptions to patients. Thus, medical errors attract lawsuits seeking compensation for harm caused to the patient. According to Lin and Watanabe’s article in 2007, “Hospital Drug errors far from uncommon,” the case of actor Dennis Quaid suing Ceders-Sinai Medical Center for overdose prescription given to his newborn twins presents the best example of medical errors and their legal ramifications (Lin, & Watanabe, 2007). It is reported that the twins received a dosage of heparin that was 1000 times higher than the intended dosage of the drug.
According to the article, the medical error was caused by the administration of a dose with a concentration of 100,000 units per milliliter instead of the recommended dosage of 10 units per milliliter. The mistake is partly attributed to the improper packaging of the drug by the manufacturer, Baxter Healthcare Corp. The packaging of the 10,000-unit dose resembles the recommended 10-unit dose contributing to the wrong prescription. Heparin along with other blood thinner drugs such as warfarin, insulin, and morphine has an associated risk of being prescribed wrongly by healthcare providers and all have potential adverse effects on the patient. Drugs such as protamine sulfate help to reverse these effects by promoting facilitating a normal blood clotting process. In the case of actor Quaid’s twins, the patients received a high dose of heparin intravenously. The nurses, after realizing their mistake, attempted to reverse the effects by administering protamine sulfate, which helped to stabilize their deteriorating condition.
Implications of the Quaid’s twins medical error to Nursing
The incident involving Cedar-Sinai Medical Center and Quaid’s twins has brought to the fore problems facing the healthcare industry with regard to medical errors. Various stakeholders including the drug manufacturers have undertaken various steps to avoid the recurrence of heparin medical errors. Baxter Healthcare now repackages heparin into two distinct doses easily identifiable to avoid the wrong prescription. Other measures include labeling a distinctive color for each dose and a conspicuous name display of the drug. The Food and Drugs Agency (FDA) requires that the manufacturers give sufficient drug information including concentration and dilution volume (FDA, 2011) to ensure that drugs remain distinct from each other and also help to distinguish between doses; a major cause of heparin medical errors.
Since the Cedar-Sinai medical center incident, hospitals have also taken necessary measures to avoid heparin-related medical errors. The heparin in the pediatric unit has been replaced with a saline solution in both adult and pediatric units. In addition, to avoid prescribing a wrong dose, the highly concentrated heparin dose is kept separately from the lower concentrations. Most hospitals have embarked on retraining their nurses and pharmacists on administration of medications in order to improve patient safety (Aspden, Wolcott, & Bootman, 2006, p.142). Other hospitals opt for independent professionals in the healthcare industry to facilitate proper checking of the medication prior to administration.
Other measures recommended to reduce medical errors include use of a computerized system with a bar code scanner. The computer system will help confirm the identity of the medication and its dosage before administering to the patient. The FDA requires that all manufacturers put bar codes on drugs to facilitate the computerized check system and prevent medial errors.
Reference List
Aspden, P., Wolcott, J., & Bootman, J. (2006). Preventing Medical errors: Quality Chasm Series. New York: Alan Wiley & Sons Inc.
FDA. (2011). Drug Safety and Medication errors. Web.
Lin, R., & Watanabe, T. (2007). Hospital drug errors far from uncommon. Los Angeles Times.