Medication errors: Wake-up call not to be ignored
The Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA, asks that health care providers pay special attention to the recent medication errors caused by misplaced decimals.
The Washington Post recently reported an error involving a decimal point that went unnoticed, resulting in the death of a nine-month-old baby girl. The baby’s physician ordered ".5 mg" of morphine to be given intravenously for the treatment of post-operative pain. A unit secretary reportedly did not see the decimal point and subsequently transcribed the order to the medication administration record (MAR) as "5 mg" of morphine. The nurse who administered the morphine did so according to the order on the MAR without questioning the order, then repeated the dose two hours later.
Approximately four hours after the second dose, the baby stopped breathing and went into cardiac arrest.
The Nov. 15, 2000, issue of ISMP’s Medication Safety Alert! describes a very similar incident in which an infant died after receiving 5 mg of morphine that was intended to be a dose of ".5 mg."
The irony in these two deaths reported by the ISMP lies in the fact that this is one of the first types of errors and medication safety issues addressed by that organization nearly 25 years ago. The omission of a leading zero in decimal doses (0.5) has long since been addressed by the ISMP and other organizations. In 1996, the first recommendations issued from the National Coordinating Council for Medication Errors Reporting and Prevention were aimed at establishing safe prescribing practices through avoidance of a short list of dangerous abbreviations and dose expressions, including the "naked decimal point" described in the patients above.
It’s time for the health care community and those in its teaching institutions to adopt and enforce the prohibition of knowingly dangerous ways of communicating information about medications. To help in this effort, ISMP has published a table of the abbreviations and dose expressions most often associated with misinterpretation and patient harm (as reported to the USP-ISMP Medication Errors Reporting Program). (To see chart, click here.)
For more information about the ISMP and the service it provides to health care professionals, visit www.ismp.org.
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