This year marks the 40th anniversary of the Medication Error Report column in Hospital Pharmacy. Initiated by Michael R. Cohen in March 1975 under the name Medication Error Reports, this monthly column reviews medication errors that have occurred in health care facilities, analyzes potential contributing factors, and offers process solutions. From its inception, the column focused on what happened not who did it. Though safety has long been a goal in the medication process, the discussion of specific medication errors was not shared in publication or open forums in the mid 1970s. The assumption that medication errors were the result of poor systems or procedures and that preventive strategies could be built through education and alertness of personnel was ground breaking. Reporting errors to an external system was not yet part of our professional efforts toward safety surveillance. In fact, this was long before the Aviation Safety Reporting Program was created, and it would still be another 25 years before the landmark publication of To Err is Human, Building a Safer Health System.¹ 

In a recent conversation with Dr. Cohen, he noted that the column’s creation occurred as a result of a conversation with Neil Davis, Hospital Pharmacy’s Editor-in-Chief at that time. The collaborative efforts of these individuals regarding medication safety laid the foundation for further accomplishments in improving medication processes. In fact, both men appeared on the very first Dateline NBC (March 31, 1992) to discuss fatal medication errors.²

Today, the monthly column is titled ISMP Medication Error Report Analysis, authored by Michael Cohen and Judy Smetzer. It is one of the most read columns in Hospital Pharmacy, and it isalways -thought-provoking and helpful to our practices and discussions regarding patient care safety. It is a valuable contribution to our readership and to all health care professionals involved in the delivery of -medications to patients. A reprint of the very first Medication Error Report column is provided at the end of this Editorial. I encourage everyone to read the first medication errors that were discussed in 1975, as they represent the groundwork of many preventive strategies that are in place today. These reports involving the hazards of verbal ordering and abbreviations are as topical now as they were then.  

In addition to the column’s 40th anniversary, the Institute of Safe Medication Practices (ISMP) recently celebrated a 20th anniversary in 2014 as a nonprofit organization dedicated to the education of the health care community and consumers regarding safe medication practices. As is the case with most -anniversaries, it is a time for reflecting on the past and planning for what is to come. Despite our best efforts, medication errors remain a cause of patient mortality and morbidity.³ Health care systems are dynamic and complex processes; our preventive strategies should be as well. 

REFERENCES

1. Kohn LT, Corrigan J, Donaldson MS, eds; Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC; National Academies Press; 2000.
2. Cohen MR. Prescription for safety in health care. Am J Health Syst Pharm. 2002; 59:1511-1517.
3. Mayo Clin Proc. 2014;89(8):1116-1125.
   
   

MEDICATION ERROR REPORTS

Compiled by Michael R. Cohen, Assistant Editor [originally published in Hospital Pharmacy, vol. 10, no. 3, 1975]

These medication errors have happened in hospitals at least once. They will happen again–perhaps at your hospital. Through educational alertness of personnel and procedural safeguards, they can be avoided. 

Error 1

An order was written, “4 U Lente Insulin.” Because of poor handwriting, the U was mistaken for an O. The patient received 40 units of Lente Insulin.

The abbreviation “U” should not be used; the word units should be spelled out.  

Error 2

An outpatient prescription was written 

Florinef #25

Sig: As Directed

The pharmacist mistook it for Fiorinal. If the handwriting had been studied carefully, the prescription would have been obvious. However, 2 out of 5 other pharmacists when asked hurriedly to read the prescription made the same mistake.

Pharmacists must take care in reading prescriptions. The prescribing physician was asked to indicate the desired strength and specific directions in the future. If he had done so originally, the pharmacist would not have made the error. Patient instructions are also necessary for proper compliance. 

Error 3

As order was received in the pharmacy for “1 mg Synthroid.” When the pharmacist checked the original order in the chart, he found that the physician had ordered .1 mg Synthroid. The decimal point was placed directly on a line on the order sheet and was not obvious.

The error was prevented. The confusion should have been avoided if the physician had written 0.1 mg. All labeling, formularies, and newsletters should also carry out this format. A long-range solution to this recurring problem is the use of the microgram designation for amounts less than 1 mg.

Error 4

A physician gave a verbal order for 16 units of regular Insulin. The individual taking the order thought the physician said 60. Sixty units were administered. 

This type of error could be eliminated if no verbal orders were accepted for insulin. If verbal orders were required, the individual taking the order should read back carefully to the prescriber, “16, that is one-six regular units of insulin”. Besides hearing the order correctly, the person involved must transcribe it onto the chart of the right patient.  

^*Editor-in-Chief, Hospital Pharmacy, and Clinical Professor, Emeritus, Department of Pharmacy Practice, University of Kansas, School of Pharmacy, Kansas City/Lawrence, Kansas