Learning from mistakes, the hard way

Name mixups are often embarrassing but sometimes can be fatal. Nurses and pharmacists at Methodist Hospital in Indianapolis killed three babies due to human error last month. Hospital personnel routinely dispense a drug called heparin to "flush" intravenous lines and prevent blood clots in the IV catheters. At Methodist Hospital, a pharmacy tech accidentally stocked a few vials of adult-dose heparin in the neonatal ICU. The highly concentrated medicine killed three of the six premature babies who received it in one day, despite the fact that the adult vials were labeled differently than infant-safe drugs.

The Institute of Medicine, a government-commissioned, independent advisory agency, estimates that more than 450,000 medication errors occur every year in U.S. hospitals. Not all those errors kill someone, but they all make people sicker. (About 7,000 cause patient deaths.) The mistakes range from oversight, such as hospitals not asking patients about their allergies before dispensing medicine, to ignorance, such as a pharmacist not asking a doctor to clarify illegible handwriting.

About a month before the incident at one of Indiana's largest hospitals, a cancer patient in Edmonton, Canada, died after an incorrectly programmed infusion pump forced a dose of chemotherapy into her blood over the course of four hours instead of the prescribed four days. The woman's cancer center reported that two experienced nurses checked the pump but missed the error.

The Institute of Medicine recently published a new report on the causes and effects of medication errors. The report hints that pride often stands between caregivers and patients. "In the past the nation's health care system has generally been paternalistic and provider-centric, and patients have not been expected to be involved in the process," the report summary said. Now, even doctors on television, (such as Hugh Laurie's character on the Fox drama House) can be mean-so mean it's funny. "I care so little, I almost passed out," says the crude-yet-archetypal Dr. Perry Cox on NBC's comedy Scrubs.

Carelessness in real life is rarely funny. The Institute of Medicine report calls for a dose of humility along with caring enough to prevent nightmares like the one in Indianapolis. "Doctors, nurses, pharmacists and other providers must communicate more with patients at every step of the way and make that communication a two-way street, listening to the patients as well as talking to them," it read. "They should also be more forthcoming when medication errors have occurred and explain what the consequences have been."

Methodist Hospital has set up a safety net of checks and double-checks in the aftermath of its tragedy, with support from other hospitals in the Indianapolis area. An Oct. 1 editorial signed by nurses from health-care agencies around the city read: "Certainly, no one ever wants to see a tragedy like this occur, but the fact remains that humans-even highly skilled health-care professionals-make mistakes. It is crucial that the system learn from this incident and put in place measures to protect patients, their families and health-care professionals themselves."

The nurses also asked for support from the public.

"The nurses and pharmacy technician involved-indeed the entire health-care community-share the burden for the deaths of these children," the editorial read. "This was everyone's worst nightmare."