Wednesday, December 8, 2010

Simple Way To Reduce Medication Errors

Take a close look at the picture above. If you were looking down into the anesthesia cart drug tray, this is what you would see, a whole drawer of lookalike drug caps. The four drug bottles on the left are different from the ones on the right but you would be hard pressed to tell the difference with a quick glance. The green cap on the left belongs to a bottle of oxytocin while the green cap on the right belongs to dopamine. Think there would be major repercussions if those drugs got mixed up and was given to a patient? The gray cap on the left is metoprolol while the cap on the right is potassium. If you were in a hurry and reached for the metoprolol but accidentally pushed potassium, think the patient will have a problem with that?

Well, you might ask, how about making the bottles of different shapes and sizes. Unfortunately many of the drugs come in one milliliter quantities so even the bottles are practically identical. The picture on the left shows a bottle of phenylephrine next to a bottle of metoclopramide. Identical white caps, identical sizes and shapes of containers. Occasionally I've caught the pharmacy put the wrong drugs into the wrong section because they look almost exactly the same.

I don't understand why drug companies have to choose the same color caps for their medications. With a whole rainbow of colors to choose from they select the same shades of gray or green or blue or yellow. Or they get lazy during their marketing meetings and simply choose white. They could certainly make the bottles different too. Use a colored glass instead. Perhaps the pharmas could even dye the drugs a certain color to make it more noticeable if you're drawing up the wrong medication. Right now it's easy to tell if you're giving a patient propofol because it's the only white opaque drug. (Don't get me started on how it can get confused with intralipids.) What if all the drugs had different colors. Make all the muscle relaxants red. The antihypertensives green. The vasopressors orange. The possibilities are endless.

You say it will drive up the cost of manufacturing these generic drugs? Well, what is the cost of giving the wrong drug to a single patient? Besides the harm to the patient, the cost of taking care of the patient after a major medication error along with the inevitable lawsuit can reach into the millions. With healthcare mistakes causing thousands of deaths a year, I think this is one area that can easily be corrected with minimal expenses to everyone.

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