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Update on Medical Mistakes

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Here are some follow up articles, quotes, and data following up the news from the other day that Dennis Quaid's twins were impacted by a medication error at L.A.'s Cedar-Sinai hospital.

This article points out that seven children were impacted by this error at Cedar-Sinai, three showed signs of overdose. Some of the data on how pervasive this problem is:

U.S. Pharmacopeia is the national leader in tracking hospital mistakes and they say there are a lot of them.

“People need to know that medication errors are frequent,” John P. Santell, of U.S. Pharmacopeia, said.

There are an estimated 1.5 million adverse drug events each year according to the Institute of Medicine. In particular, accidents with heparin are so common and so potentially harmful, it is on the “high alert” list posted by the Institute for Safe Medication Practices.

“Over a six year period from 2001 through 2006 we had over 20,000 error reports involving the drug heparin, reported to USP. Of those, about 3.6 percent were categorized as harmful,” Santell said.

U.S. Pharmacopeia says the figures are derived from what hospitals report voluntarily even anonymously — the actual number of errors they believe is much higher.

When data on problems like this rely on self reporting, it's understandable how the actual numbers would be much higher.

This article, from Indianapolis, follows up with parents of those killed by the same error last year. A dad is quoted as saying:

“It was inexcusable the first time it happened, so there should be no reason something like that happened again,” said James Daniel Soots, whose son survived a heparin overdose at Methodist in 2006.

The families took action to try to help prevent future occurrences

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Afterward, local families and caregivers worked to get the word out that the Baxter Healthcare vials were similar and that all medical centers should be on alert, and have prevention plans in place.

I wonder how that is going? We need more awareness and more prevention.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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