Tuesday, July 22, 2008

The Heparin Mishaps: Would More Technology Help?


Dennis Quaid? Heparin? Confusing, perhaps, but there have been several recent cases of overdoses of the drug heparin. One case unfortunately involved the children of actor Dennis Quaid. Some have proposed that automated systems may have prevented these errors, but the Wall Street Journal's health blog argues otherwise:

There’s just one problem in this case: automation wouldn’t have done much for the tots in Texas. A pharmacist made an error mixing heparin solution, often used to flush IV lines — and IV flushes often aren’t part of physician orders anyway. You can read the statement from Christus Spohn, which also says there’s no indication as yet that heparin contributed to the deaths in the NICU.

Doctors typically prescribe a dose of a particular drug over a particular time, and whether it should be administered intravenously or by mouth, for example. But a pharmacist often decides just how the drug will be prepared, whether by syringe into an IV or pre-mixed with saline. The pharmacist may note that a heparin flush is indicated before and after administration, or the nurse may know that it’s just part of the standard procedure.

The article does go on to note that some advanced systems do exist, but even they have their drawbacks:

Another up-and-coming technology might have helped the Quaids, but not the Texas tykes: Bar Code Medication Administration, or BCMA. Those systems require medications to be labeled with bar codes in the pharmacy identifying drug, dose and patient, and then checked — via scanner and computer — against codes in the medical record and a patient armband. But if the wrong dose is mixed and mislabeled in the pharmacy, overdoses can still occur.

“There still is that interface of human to computer that is always going to be plagued with problems,” Zachary Stacy, an associate professor at the St. Louis College of Pharmacy, tells Health Blog.


Clearly, the human element means these systems will always have some level of error, but I think this should not be used as a strong argument against their use. Any reduction in the rate of errors is an improvement, even if not all errors can be eliminated. What these hospitals really need to do is examine the processes and safeguards they had in place and why they failed to prevent this error. If they have too few techs who are perhaps overworked, the solution may actually lie in hiring more staff rather than switching systems.


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