To prevent medication errors, trust but verify

One of the benefits of consumers seeking to become more informed about their health care is that many of them have also stepped up efforts to become more directly involved in error prevention. I’m convinced that patient involvement is an absolutely critical component of patient safety. As health care providers, my colleagues and I need to engage patients not just as a disease or injury in need of our expertise and care, but also as equal partners in gaining positive treatment outcomes.

This concept really hit home last week when a close friend of mine, a cancer patient, related an experience that happened to him when he went to a health care facility for chemotherapy. He told me about it because he thought it could become an important learning experience for patients and consumers alike. What happened might have been life-threatening had it not been for simple steps that his doctor and nurse took just before he was to receive his IV chemotherapy: they made sure they mentioned the name of the cancer drug he was supposed to get and also involved him during the drug administration process.

After he settled into the infusion room, his nurse came by and said that he would be getting cisplatin. However, during the visit with his doctor just an hour before, he heard him say he’d be starting a cycle of three treatments with an IV drug called paclitaxel. The thought of getting cisplatin was a big surprise since, in the past, he’d had a serious allergic reaction to it. He remembered it well because it was the first time he had any sort of serious reaction to any of the cancer treatments. He described it as “a little scary,” as the allergy symptoms came on rapidly and strong and the nurses had to jump into action with Benadryl, nasal oxygen, taking vital signs, etc. Fortunately, he recovered fairly quickly, but it wasn’t a pleasant experience.

He mentioned that some of the nurses at the facility don’t usually tell him what drugs he’ll be getting. But fortunately, in this case, this particular nurse did inform him he’d be getting cisplatin, just as she was ready to hang the bag of chemo. Otherwise, he said he’d probably just have assumed he’d be getting the paclitaxel his doctor said he’d be getting.

Armed with the knowledge of the drug name that his doctor shared, as well as the name of the drug that caused the past allergic reaction, as soon as he heard the nurse say “cisplatin,” he mentioned the previous reaction and asked her to check with the doctor. She said she would and she did. That resulted in the order being changed to paclitaxel, the correct drug.

It’s unclear how the mix-up occurred in the doctor’s office, but the important thing is that my friend was able to stop an error in its tracks. Had he not known the name of his drug, and had the nurse not mentioned what she had in hand, he may not have been able to halt what very well might have been a more serious second allergic reaction, possibly even anaphylaxis, a more severe, life-threatening kind.

My friend was right. This event should serve as an important lesson, not only for cancer patients but for caregivers as well. Our medication error databases are replete with incidents of medical error, including some that were fatal, that could have been prevented had an observant and informed patient or family member been engaged in the care. Some of these medication errors are directly related to wrong drug, dose or providing the wrong directions for use.

Clinicians must take advantage of a patient’s willingness to participate in their care by suggesting actions to reduce the risk of error. There must be clear proactive communication between nurse, doctor, pharmacist and patient. It’s not enough to just know that you are getting chemotherapy or an antinauseant. Patients are strongly encouraged to know about their therapy, including the exact names and doses of the drugs. They need to ask questions and seek satisfactory answers before any medication is given. If the patient is not well enough to do this, then a family member or friend should be made fully aware and be prepared to ask questions on the patient’s behalf.

It’s important that you choose health care professionals that you trust. However, all of us are human, so mistakes can and do happen. We all need to accept the fact that the time has long past when the doctor can just say, “Take two of these and call me in the morning.” Trust, but verify.

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