Responsibility for Checking the Dose
On August 25th, CBS News’ show 60 Minutes did a report on a serious drug overdose given to two newborn infants. The infants survived, but similar problems have occurred in other hospitals with tragic outcomes. The reporters kept asking “how could this happen?” and made the point that three people had responsibility for checking the dose. The report didn’t go into enough detail to answer some of the obvious questions about responsibility, but several thoughts came to mind, not about this specific incident, but about drug therapy in hospitals in general.
1) How rushed was the staff? There are serious staff shortages in just about every health care profession, even while the need increases. There’s an estimate that by the year 2020 there will be 157,000 unfilled pharmacist jobs. By 2025, there may be a shortage of 500,000 nurses – in 2007 the immediate shortage of nurses was estimated at 116,000. So far, the answer to the problem has been to increase work-load, increasing productivity. It also increases the risk of error.
2) Was the computer system set to prevent errors? A well designed computer program would stop an adult dose being ordered for an infant – it’s not a major bit of programming. Was it?
3) Was there a pediatric pharmacy, preferably with a pediatric pharmacist on duty? If there’s an overall staff shortage, it may be hard to recruit suitable specialists, but it’s a lot simpler to set aside a space on the unit and only stock it with appropriate drugs. That isn’t an infallible system, because older children may requite adult doses, but it helps.
There’s no way to completely avoid human errors; there will always be tragedies like this one. As we become more reliant on drugs therapy, and as the aging population means that more people will require drugs, we’ll need more professionals and better systems, and we should address the problem as soon as possible. Right now there’s a shortage of over 700 faculty positions in nursing schools, which means that we’re losing the ability to train nurses to make up the shortage. Pharmacy schools report 417 vacant faculty slots, and dental schools need about 400 more professors. That’s going to be a problem, very soon.