I have included a link below to a recent article that caught my attention. It conerns a recent lawsuit involving a drug error at Huntsville Hospital.
This is a difficult topic, because everyone in healthcare likes to act like this never happens, yet we all know it can and does. I want to be frank with you about this difficult topic.
First of all, please know my heart: it is my deepest desire, above all else, that no patient would ever experience any harm from a mistake my staff or I made. Thankfully, that prayer has been answered up to now, and I continue to petition for God’s daily guidance. Our goal is to always have the right pills in the right bottle for the right patient.
Second, we take a number of steps to prevent drug errors. I always tell our staff: never work faster than you think is safe. While our wait times are very short, I much rather you wait an extra 5-10 minutes during a particularily busy time and know every prescription is 100% right. Don’t rush!
Third, one of the advantages of local pharmacies is we know local prescribing patterns. Often, drug mistakes are caught because we know, “Dr. X typcially doesn’t prescribe this drug. Let’s double check…”
Fourth, look-alike/sound-alikes are always on our antenna (also know as LASA errors.) All of our LASA drugs have tAlL mAn letters to help differentiate them. Also, we have LASA stock segregated from regular stock. That is the type of drug error described in this article: Tegretol and Trileptal have similar names, dosages, and indications (both are used for seisures).
Finally, we encourage patient guestions. We always tell our patients, “if anything looks awry, always tell us. It could be something innocent (like a different manufacturer) but we can’t know unless we talk.” That is what is concerning about this example. If the article is accurate, then someone didn’t take the time to double check. Humility in healthcare is not weakness: double check!
I do not cast judgements on anyone mentioned in this article, as there may be a number of key facts missinng. That being said, I could see based on my experience how something like this could easily happen. Also, as a parent it makes me thankful that it appears this young lady made a full recovery.