Small Patients, Big Consequences in Medical Errors

When 6-year-old Chance Pendleton came out of surgery for a wandering eye, it was obvious that something was not right. “He was crying hysterically, vomiting and kept saying, ‘I wish I was dead,’ ” his mother, Grace Alexander, of Paris, Tex., recalled. The boy had been through surgery before and had never reacted this way. “The nurse was quite peeved and wanted me to calm him before he disturbed anyone,” said Ms. Alexander, who said Chance was denied more pain and anti-nausea medication. “She thought he was just throwing a tantrum.” After about 20 minutes, another nurse walked by, and Ms. Alexander beckoned her for help. The nurse checked the intravenous line in Chance’s ankle and saw that it wasn’t inserted correctly. He wasn’t receiving any medication. She immediately fixed it, bringing relief to Chance in a matter of seconds. Medical mistakes, though also common in adults, can have more serious consequences in children, doctors say. The actor Dennis Quaid’s newborn twins nearly died last year after receiving 1,000 times the prescribed dose of a blood thinner. Other infants have died from the same error. A study in the journal Pediatrics in April found that problems due to medications occurred in 11 percent of children who were in the hospital, and that 22 percent of them were preventable. An Institute of Medicine report nearly a decade ago highlighted the prevalence of medical errors, and they are still a major problem. “There’s been slow progress in the decline of these errors,” said Dr. Peter B. Angood, chief patient safety officer of the Joint Commission, the independent hospital accreditation agency. The agency recently called on hospitals to further reduce medication errors in children. Children are also the victims of diagnostic errors, incorrect procedures or tests, infections and injuries. Medical errors pose a greater threat to children than to adults for a number of reasons. They are physically small, and their kidneys, liver and immune system are still developing. Even a tiny increase in the dose of medication can have serious effects — especially in babies born prematurely. And if children take a turn for the worse, they can deteriorate more rapidly than adults. Children also are less able to communicate what they are feeling, making it difficult to diagnose their problem or know when a symptom or complication develops.

Please click on the link below to read the New York Times article:

http://www.nytimes.com/2008/09/15/health/healthspecial2/15mistakes.html?_r=1&ref=health&oref=slogin

For more information on defending medical malpractice and nursing home matters in Florida contact Howard Citron at The Citron Law Firm, P.A. – www.citronlegal.com.

What’s in a Name? When It Comes to Drugs, Plenty

You say tomato, I say tomahto. Which is all well and good as long as we’re talking about fruits and vegetables — but not so good if the nurse says “fentanyl” and the hospital pharmacist hears “sufentanil,” as happened to one patient preparing for an endoscopy. The patient, given an opioid about 10 times more potent than the one prescribed, ended up in cardiopulmonary resuscitation. The problem of sound-alike/look-alike drug names and its close cousin — plain old mispronunciation — abounds. The dilemma would almost be comical, except that people can die. “[Mispronunciation] is more than a challenge, it’s also a danger,” said Robert Stanberry, assistant professor of pharmacy practice at Texas A&M Health Science Center Irma Lerma Rangel College of Pharmacy. “If you pronounce it wrong, you may end up with the wrong drug,” added Marilyn Storch, coordinator for all patient safety projects and the health care quality and information department at U.S. Pharmacopeia (USP), the official “standards-setting” authority for medications, dietary supplements and other health-care products sold in the United States. And more words — and syllables — are entering the drug world all the time. “As drugs proliferate, they start to sound alike, like Celexa and Celebrex,” said Dr. Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City. “It’s just going to get worse with increases in the number of drugs and in the number of unfamiliar names.” Also, bear in mind that for countless physicians, many medications that they were trained to pronounce and prescribe when they were in medical school are no longer used, Kennedy added. The Celexa/Celebrex combination is a classic example, but there are others. Losec, for heartburn, was confused so often with Lasix, a diuretic, that the name was changed to Prilosec. But now that gets confused with Prozac, according to a USP report. And the Alzheimer’s drug Reminyl was changed to Razadyne after mix-ups involving Amaryl, which lowers blood sugar. The mix-ups reportedly resulted in two deaths. And what about names that are just too long? The generic name for Flurizan, an investigational Alzheimer’s drug, is tarenflurbil. “It’s almost too many syllables to pronounce,” Kennedy said. Does anyone know how to pronounce bapineuzumab, another investigational drug for Alzheimer’s? The report issued earlier this year by USP on the relationship between drug names and medication errors reviewed more than 26,000 records. It found almost 1,500 different drugs implicated in medication errors as a result of names that looked or sounded alike. The drugs in question added up to 3,170 pairs, double the number of pairs found in a 2004 report. According to the document, 1.4 percent of the errors resulted in patient harm, including seven that may have played a part in patient death.

Please click on the link below to read the Health Day article:

http://www.healthday.com/Article.asp?AID=617849

For more information on defending medical malpractice and nursing home matters in Florida contact Howard Citron at The Citron Law Firm, P.A. – www.citronlegal.com.