Medication errors are largely the result of human error, and it is primarily considered the responsibility of the nurse delegated to administer medication. Such was the case when an experienced hospital nurse administered potassium chloride to a patient after checking the vial three separate times to be sure it was the drug prescribed, which was Lasix (Green, 2004, p. 37). The patient died, and a subsequent investigation found that the vial was labeled correctly and that the nurse had no explanation for the error (Green, 2004, p. 37).
Although at first blush, the nurse appears to be negligent and fully responsible for the "look but fail to see" error, "an inquiry that is judgmental and narrowly focused on the nurse is likely to overlook system and procedure faults" (Green, 2004, p. 37). For example, the 1998 Patient Safety study found that potassium chloride had been confused with other drugs, Lasix included, on frequent occasions because of similar packaging (Green, 2004, p. 37). In addition, the drawer where the drugs were kept had no dividers to keep different drugs separate, so the potassium chloride could easily have fallen into the Lasix part of the drawer (Green, 2004, p. 37). One source reports that "hospitals are sacrificing patient safety for a better bottom line," scheduling trained nurses for too much overtime and allowing untrained nurses to perform procedures they had not been trained to do ("Your Health: Medical Errors Linked to Nurses," 2000).
These are errors in the hospital's procedures, but similarities in packaging are attributable to the drug manufacturers, who have been negligent in properly distinguishing their products. An example is the case of the Quaid twins, who received massive doses of heparin(10,000 units instead of the 10 units prescribed(due to the fact that the drug's maker, Baxter Healthcare Corporation, used similar packaging with "blue backgrounds and very small pr...