Medication and Death in U.S. Hospitals

The problem is so prevalent that the American Medical Association has launched a Medication Error Reduction Initiative (Voelker, 1996, pp. 1537-1538). The Joint Commission on Accreditation of Healthcare Organizations has reviewed more than 200 sentinel events and found that the most common category of such events was medication errors. Of these, the most frequently implicated drug was potassium chloride according to the Sentinel Event Alert (1998). This paper will look at ways in which hospitals are responding to reduce these mistakes.

A recent study of two hospitals found four major causes for medication errors (Davis, Leape, Nightingale, Weart, & Galper, 1997, p. 30). The four causes were: lack of adequate knowledge about the drug, insufficient knowledge about the patient, failure to adhere to long-established rules for prescribing (e.g. route and frequency of administration) and mental slips or lapses of memory.

One cause of medication errors stems from the illegibility of the handwriting of many doctors (Wintrode, 1990; AMA, 1997). A recent study showed that more than 50 percent of adverse drug events stemmed from errors made at the ordering stage (Davis, Leape, Nightingale, Weart, & Galper, 1993, p. 2). About one third of these mistakes, and 42 percent of the life-threatening and serious events were considered preventable. In hospital studies

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n water, and when it is added to a hanging IV bag, it can form a layer on the bottom next to the outlet. This can result in the patient receiving a bolus of the concentrated potassium chloride, which can be fatal. The bag needs to be agitated after the potassium chloride is added so that it can be thoroughly mixed and the patient receives the medication in the diluted form. Potassium chloride concentrate is now labeled "potassium chloride concentrate for injection" in an attempt to avoid it being given incorrectly, or mistaken for sodium chloride (Cowley, 1995, p. 4). The USP now requires this new labelling by manufacturers for potassium chloride in 20 Meq per 20 Ml concentrations. They also now require manufacturers to use black caps for potassium chloride for injection concentrate with the imprint, "Must be Diluted", (Davis, 1995, p. 14) to further prevent mistakes in dosage. In addition, Davis says, manufacturers have changed the labelling of IV potassium salts by enlarging the print size to lessen the chance of them being mistaken for other products. Lilley (1996) reports that the color-coded labels and the removal of potassium chloride concentrate from the unit floor stock have helped reduced the incidence of mistakin
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Some common words found in the essay are:
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Approximate Word count = 1592
Approximate Pages = 6 (250 words per page)

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