As posted by the Wall Street Journal:

Article

My comments:

Christus SPOHN Hospital Systems in Corpus Christi, TX recently released information concerning an overdose of 17 neonatal patients in their intensive care unit. The error was identified at the preparation step in the pharmacy, whereby the pharmacist or technician used the incorrect concentration of Heparin to mix intravenous doses. As a result, the patients received a much higher dose that necessary for clinical efficacy.

The article questions currently available technologies in healthcare and starts with Computerized Provider Order Entry (CPOE). Appropriately noted, CPOE does nothing to prevent a preparation error directly. However, tremendous value lies in reviewing hospital wide medication use practices when implementing a CPOE system. Standard concentrations of medications, an evaluation of currently used medications per unit, and order properties are among many important factors.

Bar Code Medication Administration (BCMA) is mentioned as a possible solution, but quickly realized to have little impact on a medication that was made incorrectly. Automation for the creation of IV solutions presents a potential fix as well. In the end, pharmacy informatics professionals know a system is only as good as the pharmacists that build it. Humans are required to check the medications being loaded into all automation, and as with these preparation errors are subject to potential error.

Healthcare consumers are looking for a black/white fix to these potentially harmful human interventions, but today none exist. In the end, as pharmacists it is our professional obligation to ensure medications are ordered, prepared, delivered, administered, and monitored as accurately as possible. This is a great article to reference when you feel rushed to get those medications up to the unit. Take your time and double check. It could save a life.

NCPA Article Link