Tenfold errors can lead to tragedy

August 21, 2006

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.

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.

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.

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."

"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.