Nurse's Notes
2005 March View
MEDICAL MISTAKES
Some months ago I wrote about the medical “miracles” that are now
almost everyday occurrences. This month I want to mention the other
side of the coin—medical mistakes.
There isn’t a doctor or nurse in practice that hasn’t goofed at one
time or another. We are all human. We pray that we will not make a
mistake, or that if we do, it will not be of serious consequence,
but it happens to the best of us. I know for sure that I have made
two mistakes with patients—neither of them, thank God, serious, but
both of them burned in my brain. I wonder how many I have made I
didn’t even know about?
Many of the mistakes are medication errors. So many medicines look
and sound alike—ephedrine and epinephrine, for example. In looking
at this type of error, hospitals and accrediting bodies are now
requiring several new practices—among them using different colors
and types of labels and not using certain abbreviations in writing
dosages.
Safeguards are built into the system. Every nurse is taught the five
“rights”: the RIGHT dose of the RIGHT medicine to the RIGHT patient
at the RIGHT time by the RIGHT route. Pharmacies now dispense
medicine in “unit” doses—the usual dose in a separate package.
Nurses question when the medication being prepared for the patient
requires opening more than one package—this is a red flag.
Still, errors occur. As the consumer, you can help. Know the names
of your daily medicines--“I take a pink pill in the morning and a
yellow pill at night” is not sufficient information. Know what your
medicine is for—is it for high blood pressure? Why did the doctor
prescribe this drug? If you can’t remember the names and usage,
write it down on a card and carry the card with you. When you
receive a new or refilled prescription from the pharmacy, look at
the medicine. If the prescription is new, talk with the pharmacist
about the reason for the drug. If this is a refill and the pills are
different, ask why. It may be a new brand or a generic, but it also
may be a mistake.
In the hospital be sure to question anything not in the normal
routine. If you have never had medicine at 10 a.m., then question
why today you are getting medicine at 10 a.m. This does not make you
a “bad” patient. Members of your family or friends who stay with you
should also be aware of what’s going on. If you don’t understand
something, ask. Don’t be afraid of looking ignorant—you probably are
ignorant about the problem. You’d ask your mechanic about what was
wrong with your car and how they were going to fix it—take as good
care of your body as you do your automobile.
Nurses, doctors and pharmacists are busy people—we need all the help
we can get.
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