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Avoid medication mistakes: Learn from the Quaids
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In this photo released by Harpo Productions, Inc., talk-show host Oprah Winfrey interviews actor Dennis Quaid during a taping of "The Oprah Winfrey Show" in Chicago on Feb. 19, 2009. The shows air nationally on Tuesday, March 10, 2009. (AP Photo/Harpo Productions, Inc., George Burns)
Medication mistakes happen. Dennis Quaid knows. Yesterday on Oprah he told the story of the day his newborn twins got what could have been a lethal dose of blood thinner. Fortunately, the twins are growing and thriving.
How did this happen? In the same way you arrive at work and discover you're wearing a black sock on one foot and a dark brown sock on the other.
The Quaid twins were hospitalized for an infection, and they were to get a small dose of a blood thinner Heparin to keep the IV's open. Heparin comes in different doses, and the vials have slightly different colors on their labels. When the twins were hospitalized, the more concentrated blood thinner was accidentally put in the bin that normally holds the less concentrated medicine. That's like pairing the black and brown sock. Then the busy nurse grabbed what she thought and trusted to be the right medicine just as she does every day and administered it. That's like thinking about your meeting as you get dressed; your attention goes to the more pressing concern and not the rote task.
The problem is that the consequences of unpaired socks and a lethal dose of medication are quite different.
The hospital learned from this mistake. They installed a barcode system that assures the right dose of the right medicine is delivered to the right patient.
Many hospitals leverage technology to avoid medication mistakes. If you or a loved one have an elective procedure coming up, call around and ask the hospitals, nicely, "What system to do you have in place to prevent medication mistakes?"
When you're a hospital patient, or a loved one at the bedside, you will have a "get to know you" intake session with the nurse. Say at that time, "I know how busy you are. I plan to help you help me. I'll be asking what medicine you're offering before you give it. Will that work for you?" Most nurses will sigh with relief. They come to work dreading the day they make a medication mistake.
Then when the nurse comes with medication, ask the nurse, nicely, these questions:
1. What is that medicine?
2. What does the medication do?
3. Is there another John Smith ( insert your own name) on this floor?
If it doesn't sound right, suggest, nicely, "That doesn't sound right. Could you please recheck?"
Hospitals, doctors, nurses, patients and their loved ones are all on the same team. We all want the same safe effective medical care. When you speak up, you run the small risk of offending a nurse having a bad day. That's the same nurse who is at highest risk of making a human mistake. Just do it.
Vicki Rackner MD, founder of The Caregiver Club, is a surgeon who left the operating room to help family caregivers avoid burnout, speak up with their doctors and stretch healthcare dollars. Reach her 425 451-3777 or DrRackner@TheCaregiverClub.com.
