Articles, PSQH July 21, 2011

Say No to Paper

by Barry P Chaiken, MD

Paper came one pill away from killing my 91-year-old mom. Only through luck did we dodge a medical error that could have extinguished a life that survived the Great Depression, World War II, polio epidemics, the birth of two children, the Cold War, the loss of her husband, and more than 60 years of employment. Up until her admission on May 7th, she never experienced being an ill patient in a hospital.

Mom was admitted to a hospital affiliated with her cardiologist located in Westchester, New York, a location close to the home of my sister, a trained endocrinologist with more than 20 years of clinical experience. After treatment for an upper respiratory infection, urinary tract infection, and symptoms of viral pericarditis, Mom was discharged to my sister’s home.

After a week of rest, she returned to Westchester for continued recuperation with my sister. Unfortunately, her condition worsened after a few days, leading her physician to re-admit her to the hospital. At the conclusion of a few days of further tests and treatment, she was transferred to the hospital’s co-located rehabilitation facility for several days to continue her treatments in a less acute care setting. Due to the lack of availability of required therapy over the upcoming Memorial Day weekend, we collectively decided to have Mom discharged to my sister’s home where she could receive better care.

Holiday Weekend Dangers

As Mom suffered from new onset of intermittent atrial fibrillation, the physicians prescribed Pradaxa, an anticoagulation therapy drug that greatly reduces the probability of stroke in patients suffering from atrial fibrillation. The decision to discharge my mom on the Friday before a holiday weekend immediately proved problematic. Pradaxa at the 75 mg dose was unavailable in several pharmacies in the area around the hospital.

Over a 2-hour period, working with a very helpful social worker in the hospital, we convinced the outpatient hospital pharmacy to fill a prescription for the drug. While my sister prepared Mom for discharge, I rushed down to the pharmacy with the paper prescription for 75 mg of Pradaxa. With the prescription bag in hand, I rushed up to meet my mom and sister to help them prepare for discharge.

I handed the prescription to my sister who promptly opened the packaging and looked at the bottle of meds. “This is wrong”, she shouted. “Mom should be on 75 mg not 150 mg.”

Although the prescription was written correctly, the pharmacy dispensed the wrong dose. Knowing my mom had just dodged a potentially fatal medication error, I promptly returned to the pharmacy with the incorrect mediation in hand and explained to the pharmacist what happened. All color left his face as he began to apologize profusely. He just experienced a sentinel event that required immediate and complete reporting.

Anatomy of an Error

Reviewing the sequence of events surrounding the medical error, it becomes clear how it occurred. Although the handwritten prescription was legible and correctly written for 75 mg of Pradaxa, the pharmacist mistakenly selected an unopened, 60 capsule bottle of Pradaxa 150 mg to fill Mom’s prescription. He then placed the medication in a sealed paper bag, attaching the prescription receipt to it. Had the hospital been equipped with ePrescribing and an electronic medication administration system, the system would have immediately alerted the pharmacist of the dosing error. The scanned barcode of the bottle of 150 mg of Pradaxa would not have matched the expected barcode of a bottle of 75 mg capsules.

Going forward I will never allow anyone I know to be treated in a facility that bases its medical care on dangerous paper-based processes. Nor should any American ever be subjected to such inferior care. If we continue our efforts to promote and properly deploy healthcare information technology, this soon will be true.

Excerpts from: Say No to Paper. PSQH, July/ August, 2011


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