1. Alexander, Mary MA, RN, CRNI(R), CAE INS Chief Executive Officer Editor

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Healthcare consumers have become more aware of the types and number of potentially deadly errors that occur in hospitals, in part because of recent news stories about heparin overdoses in the past year. Consumers are demanding that hospitals make public information about their infection and medication error rates and work to reduce or eliminate them. The federal government, through the Centers for Medicare and Medicaid Services, has ruled that as of October 2008, it will no longer reimburse hospitals for preventable hospital-acquired infections (see IV P.U.M.P. in this issue). As hospitals seek ways to improve their patient outcomes, nurses are, as always, on the front lines.

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The widely publicized cases of heparin overdoses (particularly the death of 3 infants in Indiana and the serious illness of the newborn twins of actor Dennis Quaid) have caused manufacturers and healthcare professionals to change the way they handle medications. The errors were caused in part by the similar packaging of widely differing dosages of heparin-10 units/mL and 10,000 units/mL.1 Healthcare providers at the hospitals had chosen the vials from supply cabinets and did not fully read the labels. They did not check one another's work to verify the correct dosages and risks to the patients.


There are a number of other potential sources of medication error:


* Ambiguous heparin dosing terms. Because heparin is used to treat an existing blood clot (therapy) or prevent one (prophylaxis), there is sometimes confusion about heparin concentration. Generally, prophylactic treatment requires a low dose, and therapeutic treatments calls for a higher dose. There are exceptions, however, and this is where mistakes can happen.


* Temporary assignment of nurses. Nurses who are temporarily working in areas where high-alert medications are frequently used might not have the education necessary to administer them appropriately.


* Pump programming errors. Human error sometimes leads to incorrect programming of intravenous pumps. This can cause all kinds of infusion solutions to be delivered incorrectly.


* Lack of uniformity of physician order forms. The different ways in which data are presented can lead to omission or misinterpretation of essential information.2



Nurses at the bedside will most often be responsible for eliminating medication errors. It is nurses who program the intravenous pumps, check medication labels, double-check other nurses' work, and review medications for possible adverse reactions.


But nurses are not alone in creating solutions to the problem. Pharmaceutical companies are already changing the packaging on high-alert medications to make it easier to note dosages. Patients, along with their families, will also have to take an active part in their own care. They should ask questions and pay attention to the medications that are administered. Physicians should work with other healthcare professionals to improve communication. And, of course, administrators should provide staff with the education and technology available to help prevent all medication errors.


We continue to have the same discussions about medication safety, yet only when tragedy occurs or celebrities are affected does the issue make headlines. We nurses have the knowledge, expertise, and technology available to effect positive change in healthcare delivery. It only takes the will to do it-no excuses.


There are a number of resources to help your institution save lives by eliminating medication errors and delivering safe, high-quality healthcare:


Institute for Safe Medication Practices:, a nonprofit organization dedicated to reducing medication errors.


Institute for Healthcare Improvement:, a not-for-profit organization for information on the 5 Million Lives campaign and other healthcare improvement issues.


Agency for Healthcare Research and Quality:, a federal government agency devoted to improving the quality, safety, efficiency, and effectiveness of healthcare.


National Quality Forum:, a not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting.


Mary Alexander




1. Landro L. Hospitals tackle high-risk drugs to reduce errors. Wall Street Journal [online]. March 5, 2008. Accessed March 5, 2008. [Context Link]


2. Harder K, Bloomfield J, Sendelbach S, et al. Improving the safety of heparin administration by implementing a human factors process analysis. Advances in Patient Safety. Vol. 3. Rockville, MD: Agency for Healthcare Research and Quality; 2005:323-332. [Context Link]