Stopping Deaths From Incorrect Drug Doses

As many as 100,000 people a year die because of medical mistakes, according to the National Academy of Science's Institute of Medicine. But a tenth of those, says Allen Vaida, executive vice president of the nonprofit Institute for Safe Medication Practices, are due to errors in administering medication — simple errors that he says are a result of a much larger problem.

"In the majority of the cases we follow up on there are many problems," Vaida says, describing overworked nurses, overcrowded hospitals, and the absence of proper manual and technical checks and balances. "It's a system breakdown."

The problem drew national attention Sunday night when Actor Dennis Quaid spoke to CBS news at length about how his newborn twins almost bled to death late last year when they were given doses of the blood thinner Heparin that were 1,000 times stronger than what was prescribed.

Vaida says Quaid and his wife aren't suing Cedars Sinai hospital for administering the wrong drug. They're suing the drug company that makes Heparin, accusing the company of negligence for not recalling old stock of the drug after the death of three infants in Indiana. After that incident, drug manufacturer Baxter redesigned the drug labels, but did not recall the old stock.

But Vaida says it will take more than relabeling what he calls "high alert drugs," such as Heparin. For certain drugs — such as insulin, cardiac drugs and opiates — some of the special checks that need to be introduced would be manual, Vaida says. Other solutions could involve new technology. He says many hospitals have begun bar-coding drugs, so that each time they administer a dose they scan the package first.

" 'Health care pros need to read the labels,' " Vaida says. "We hear this all the time: 'If only the nurse, physician pharmacist had just read the label.' "

"But humans make mistakes," Vaida says.



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