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Four tips for preventing life-threatening medical errors

Article-Four tips for preventing life-threatening medical errors

Nearly 20 years ago, the Institute of Medicine’s "To Err is Human" report helped to put medical errors in the spotlight. The IOM report suggested that preventable medical errors killed from 44,000 to 98,000 patients in hospitals each year.

Fast forward to 2016. Johns Hopkins researchers calculated that medical errors cause one in 10 U.S. deaths. Incredibly, the under-recognized cause of death ranks as the third highest cause of death in the U.S., according to the study published May 3, 2016 in The BMJ.

According to the Agency for Healthcare Research and Quality, nearly 700,000 people go to emergency departments each year because of adverse drug events, in which patients experience harm from exposure to medications.

Many use the term pharmacovigilance to describe ways in which physicians and others can prevent medication errors in medicine, according to Ronald S. Litman, D.O., M.L., medical director at the Institute for Safe Medication Practices (ISMP), a nonprofit organization devoted to preventing medication errors.

“Traditionally, medical practitioners are taught to rely on the ‘5 Rights of Medication Administration’: right drug, right patient, right dose, right route, right time,” Dr. Litman writes in an email to The Aesthetic Channel. “But the problem here is that these all rely on human vigilance, which is naturally error prone. Therefore, modern ways of preventing medication errors use technology and engineer systems to prevent humans from making mistakes.”

These four tips can help aesthetic physicians and others rely less on human vigilance and more on technology and systems, according to Dr. Litman, an anesthesiologist at the Children's Hospital of Philadelphia.

1. Prefilled syringes
Providers normally get drugs in vials or ampules, then take the liquid drug out of the vials and put them into syringes to administer to patients.

“This runs the risk of picking up the wrong ampule, commonly referred to as ‘ampule swap,’ Dr. Litman writes.

The good news is more of today’s drugs are available in prefilled syringes, where the practitioner buys the drug pre-filled and pre-labeled. Local anesthetics, often used by aesthetic physicians, are among the drugs available pre-filled.

These are better for accuracy and sterility but cost more, so many hospitals surgery centers don’t use them, according to Dr. Litman.

2. Barcoding
Once the drug is in the syringe, what’s to stop the provider from making a human mistake and giving the wrong one?

“This is a vexing area of medication safety that is not easily solved. Many hospitals have now use barcoding to enter drug administrations into the electronic health records,” Dr. Litman writes.

For example, when the doctor is ready to administer the medication, he or she scans the barcode on the syringe label, which causes a screen to pop up on the local computer that verifies it is indeed the right drug, at the correct dose, for the right patient, etc. The system can warn the doctor if the patient has any related allergies or other contraindications to using that drug.

But few healthcare providers outside the inpatient setting are set up to use the barcoding system, he writes.

“… it’s too new, but is rolling out slowly,” Dr. Litman writes.

3. Wrong-route errors
Wrong-route errors are potentially disastrous for aesthetic physicians and their patients, according to Dr. Litman. They occur when the provider administers a local anesthetic intravenously, instead of locally or around a nerve.

“Many deaths have been reported from this,” Dr. Litman writes. “For over 25 years, an international movement has been working on designing different connectors to prevent this from happening, and it’s being slowly rolled out now.”

Dr. Litman authored a paper published September 2017 in Pediatric Anesthesia about solutions for wrong route medication errors from tubing misconnections with the universal Luer connector.

“The new International Organization of Standardization standards for small bore connectors, ISO 80369 series, have been developed to reduce the risk of these types of erroneous connections. Tubing connectors for different routes of clinical application will contain differently designed connectors that are physically incompatible. However, design and manufacturing standards have progressed slowly, and clinical roll-outs have been delayed, despite the implementation of California laws to promote their use,” according to the paper.

4. Proper labeling
The Joint Commission requires specific elements to be on medication labels, such as the drug’s name, concentration, initials of person that prepared it, expiration date/time and total volume.

“It is unclear if this actually prevents errors but is meant to be consistent with USP 797 rules and regs, which is essentially equivalent to law,” Dr. Litman writes. “Also, the labels should use a standard color-coded system to help practitioners identify drugs (e.g., opioids are blue, local anesthetics are gray, etc.). Although it makes sense intuitively, this has not been proven to prevent errors more than non-colored labels.”
Physicians can learn more about how to prevent medication errors, analyze their practices for error risk and report errors at