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Saturday, January 13, 2007

The Machine was the Perp, Part 2: A drug dispensing error

I described what happened after nurses opened the drug drawer of a mis-stocked automated dispensing machine and gave adult doses of Heparin to three newborns.

That hospital unit usually only received doses of Heparin for newborns, and the vials of adult and baby doses are of similar size and color. If the hospital had consistently used vials of a distinct size or color for babies or youths, the errors would have been far less likely. The pharmacy technician would not have stocked the drug wrongly, and the nurses would not have given it to the babies.

Safeguards like this distinctive repackaging are a form of error-proofing ("pokayoke," in Japanese)--an effort to make errors impossible, or at least highly unlikely. Of course, such distinctive packaging costs hospitals time and money. Since the powerful blood-thinner Heparin is known as a hazardous medication, it's probably money well-spent.

Advice to patients and advocates: Be especially vigilant when hazardous medications are being given.

Advice to pharmacy directors: Repackage hazardous medications to consistently distinguish adult from infant doses with distinctive colors or vial sizes.

Read Nurse Mary Bylone's blog posting for more.