Medical personnel and advocates for patient safety in Kentucky and across the nation took notice as the MedStar Health system admitted to giving more than 200 patients in several medical facilities in Maryland and Washington, D.C. the wrong dosage of medication in 2010. The error didn’t result in any known medical complications, so it went undetected for about two months as clients received twice the correct dosage.
To MedStar’s credit, they admitted the medication error and disclosed the investigation they underwent. A MedStar administrator explained that they wanted to help others prevent that type of error. Outside colleagues came in to review where the errors had occurred and discuss the adjustments that they made to help with prescription safety. They talked about the discovery and how they resolved the problem. Other professionals were called to the site to find the reason for the error, review hospital procedures, and to make suggestions on minimizing the risk of future mistakes.
A drug shortage, in part, contributed to the initial problem. After being unknowingly supplied with higher dosages, the pharmacy staff still looked at the drug name and container volume, but not the concentration. The professionals suggested that double-checking the concentration of the prescription would aid in reducing errors. They also recommended clearer communication related to the substitution of different medications. They suggested tracking and recording the medications more closely.
One doctor who spoke at a medical meeting for health care professionals explained that the situation presented a great learning opportunity. He credited the institution with their public acknowledgement of the event.
Because of the openness of the hospital in disclosing the medical error, future similar mistakes could be prevented. However, if someone suffers because of a medical mistake, a personal injury attorney might be able to assist them with filing a civil lawsuit to hold the involved parties accountable for the errors.
Source: Pain Medicine News, “A Dangerous Interplay: Rx Shortages and Med Errors“, May 27, 2013