Patient Safety--Medications

“Jaded Julie, today we’re going to start talking about medication safety.”

“How can you do that, Ancient One? You don’t know the first thing about medications.”

“I certainly do. First thing every morning I take a big multivitamin pill. Besides, my colleague on this blog is a nurse who is very knowledgeable and occasionally somewhat respectful. We can do it if you promise to help.”

“Of course. I suppose we’ll start by your telling how it was in the old days.”

“When I was ill as a child, we waited all day for the family doctor to come and felt better as soon as he arrived. We didn’t appreciate how limited the armamentarium in his black bag was…some tongue depressors, a flashlight, and bottles of a couple dozen types of pills. We didn’t hear about medication errors then, probably because the meds weren’t very effective. Patients got better if they were strong and more than a little bit lucky.”

“The armamen...what? Well, those black bags were pretty small. If doctors made house calls today, they’d have to pull a trailer with a pharmacy in it.”

“To a layperson like me, the medications available now are a bewildering array. All of those brand names plus a host of generics. Despite the manufacturers’ best efforts, there are a lot of look-alikes and sound-alikes. No wonder pharmacists are in such high demand.”

“Curmudge, let’s start by listing (in order) the top 10 meds that are most commonly misused or mishandled by health care providers (1). Those folks administering these drugs should be aware that they are dealing with materials that have bad track records for safety.
· Insulin
· Morphine
· Potassium chloride
· Albuterol
· Heparin
· Vancomycin
· Cefazolin
· Acetaminophen
· Warfarin
· Furosemide”

“Good list, Julie; you and I read the same stuff. Errors that occur with insulin—at the top of the list—include look-alike packaging, similarity in brand names (e.g., Humalog and Humulin), and confusing the unit abbreviation ’u’ with the number 0.”

“Consider opioids along with morphine, the second item on the list. Similar names for these can be a source of confusion: Avinza and Evista, morphine and hydromorphone, Oxycontin and MS Contin, hydrocodone and oxycodone, and oxycodone and codeine.”

“Patients should be especially aware of this next list, because these are the principal meds that prompt their visits to the ED. Unintentional overdosing is the main reason for going to the ED; others include side effects and allergic reactions.
· Insulin
· Anticoagulants
· Amoxicillin
· Aspirin
· Trimethoprim-sulfamethoxazole
· Hydrocodone/acetaminophen
· Ibuprofen
· Acetaminophen
· Cephalexin
· Penicillin”

“You know, Curmudge, I see bad news as well as good news in the multitude of potent medications that are now available. The good news is that they can achieve cures that were only an impossible dream when you were a kid. The bad news is that mix-ups can occur more easily and result in a patient’s taking a very powerful—but wrong—medication.”

“Julie, an organization with a Lean culture will devise systems that make it easy to do the right thing and very hard to do something wrong. Until we achieve that, the old rule might still apply, ‘Patients get better if they are strong and lucky.’”

“If that’s true Curmudge, I bet that penicillin shot you received for an infection 50 years ago made you a lot luckier.”

Affinity’s Kaizen Curmudgeon

(1)http://www.medscape.com/viewprogram/7099_pnt