Of all medical errors, incorrect handling of medications is the most common. A patient will probably experience at least one medication error during a hospital stay. Most times you won’t know that a preventable error occurred – your prescription was late – or omitted – and it won’t jeopardize your recovery. But sometimes it does.
It is estimated that as many as 20 patients die each day in hospitals because their medications were botched: blood-thinner doses are doubled because a patient transfers from the Emergency Room to an ICU; an infant is given an adult dose of medication; or a look-alike medication is given by mistake. These preventable errors are, in part, because the process of ordering, delivering, and monitoring thousands of doses of medications is complicated.
Delivering the correct prescription is part of the business of health care. Hospitals know it is a complicated process. And they know there are systems and technology that make the delivery of medicine safer and less risky. Nonetheless, they simply fail to implement these programs, neglect to train their staff to use them, or, most egregiously, ignore the problem.
At the Dennehy Law Firm we believe it is critically important to look behind the error and understand the breakdown in the system. Does a hospital allow a doctor to order medications using handwritten orders that are difficult to read – or abbreviations that are misunderstood? Are computer systems connected between the hospital pharmacy and nursing stations? Between the ER and the ICU? Does staff need to toggle between different programs? How are medications labeled and stored? How are they dispensed?
In one of our cases, a young man with sleep apnea was overdosed with powerful pain medication. The medication depressed his breathing and he died. His history of sleep apnea was never coordinated with the medication order. At shift change, the nursing staff neglected to pass the information to the next shift. He was left without the close monitoring he required.
In another case, an urgently needed medication was not given in the Emergency Room because the patient was admitted and moved to another ward. The new staff failed to recognize the omission and precious hours elapsed without the urgently required medicine, resulting in permanent injury.
At the Dennehy Law Firm, we “work smart.” We dig behind the medication error, learn why the hospital’s system broke down, and use medical and pharmacy experts to assist us. We look to see whether the hospital put its own financial gain ahead of its patients. Did the hospital choose not to adopt computerized prescriber ordering systems? Did it leave the pharmacy system as a stand-alone system rather than integrate it into the hospitals’ network? We compare the hospital’s billing statement – which identifies each pill dispensed – with the pharmacy’s ability to track that same drug. When they don’t add up, it indicates that the priorities of that medical institution are skewed. And, most of the time, we find that the negligence begins long before the actual error occurs.
While past results don’t guarantee future results, we can promise that we will be diligent. And we will listen to you. We believe that focusing attention on a hospital’s pattern of omissions helps to make hospitals safer and changes the way that medicine is delivered in the future to other patients.