Tenfold drug administration errors are common and pernicious in healthcare systems, but they could be almost entirely eliminated. They occur when a decimal placement is written incorrectly or misread. Decimal errors can result in a 10-fold, 100-fold, or even 1,000-fold overdose or underdose. But experts say providers rarely need to use decimals, and, when they are necessary, many steps can be taken to limit errors.
Combine dosage danger with the fact that the cure can sometimes be worse than the dilemma, and you have the sad case of what appears to have happened at Botsford General Hospital in Farmington Hills, Mich.
A recent lawsuit alleges that a hospital patient received a 10-fold overdose of an analgesic, which resulted in a dangerous drop in blood pressure. As a result of an attempt to treat that condition, the patient became paralyzed and died. But it was the decimal error that apparently killed him.
"In examining errors, we always look to the root cause," said Hedy Cohen, VP of the Institute for Safe Medication Practices in Huntingdon Valley, Pa. "If what the plaintiffs say is true, the cause of death is the dosage error, not the subsequent treatment."
Unfortunately what may have happened at Botsford in 2003 is much too common, said Timothy Lesar, Pharm.D., director of pharmacy at the Albany Medical Center in New York and a leading national expert on medication errors. "Potential 10-fold dose errors do, in fact, happen often," he said. "We deal with them on a daily, sometimes twice-daily, basis here, as do most hospitals. Thank goodness the many layers of review we implement catch most of them."
A report issued on July 20 by the Institute of Medicine titled Preventing Medication Errors bears that out: "It is clear that 10-fold dosage calculation errors in particular are a major clinical issue," states the report. (For more on the report.) It calls for efforts to be made by health systems to avoid the use of decimals in dosing specifications whenever possible.
"Very few medications cannot be rounded up or rounded down," said Michael Cohen, ISMP president. "It is a very common error that could virtually be eliminated." It apparently led to tragedy in Michigan three years ago.
A lawsuit was filed in a Michigan court last May by the mother of 40-year-old Douglas Adams, who was admitted to the emergency department at Botsford in November 2003 with a diagnosis of acute viral pneumonia and acute pneumothorax. He was administered the anesthetic agent propofol.
The order apparently called for administration of 5.6 cc per minute, but Adams apparently received 56.6 cc/min, "10 times the amount that should have been administered," according to the suit. That resulted in a significant decrease in blood pressure, and Adams was administered the drug norepinephrine bitartrate for blood pressure support. That drug is recognized as dangerous because it results in significant vascular constriction—that's its purpose—and, therefore, can cause ischemia, infarction, and irregular heartbeat.
The suit claims that the hospital failed to adjust the amount of propofol once hypotension became present, and that as a result of the administration of the norepinephrine—which resulted directly from the 10-fold error—Adams became quadriplegic and eventually died.
In its response to the suit, Botsford and its nurses, physicians, and technicians being sued by Adams' mother, Barbara Adams, admitted that the deceased received the 10-fold overdose of propofol. The hospital and other defendants denied, however, that his subsequent paralysis and death were caused by their negligence or malpractice, as the suit alleges. They responded that neither the propofol dose nor the norepinephrine was responsible for the decedent's death.
We've noticed that you're using an ad blocker
Our content is brought to you free of charge because of the support of our advertisers. To continue enjoying our content, please turn off your ad blocker.