How Safety Protocols Prevent Drug Mistakes

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

The IOM report, To Err is Human, highlights the chilling story of Ben Kolb, an 8-year-old Florida boy who died in 1995 after he was injected with the wrong drug during a routine surgical procedure.

That case, and other medication mishaps or errors are less likely to happen in today’s hospital, says INQRI grantee Linda Costa, a nurse researcher at the Johns Hopkins Hospital in Baltimore. She says that in the wake of the IOM report, hospitals have gotten much better at protecting patients from medical mistakes, like the one that killed Ben Kolb.

About 400,000 people in the United States each year are affected by an adverse drug event, a mix-up or an error in dosage that can lead to a serious medical complication. With funding from INQRI, Costa and her colleagues are studying drug safety interventions like those that occur at the time of admission and in the risky discharge period. The INQRI study has a nurse-pharmacist team double-checking with the patient, and other sources, to make sure the patient gets all the right drugs both in the hospital and after they go home.

So far, that study suggests that the safety intervention can prevent lots of drug errors that can potentially harm patients, Costa says.

But Costa says the IOM report spurred many other safety interventions, including procedures aimed at reducing even subtle medication problems--like those that occur when a drug dose needs to be adjusted. In the past, a nurse who noticed a dose problem couldn’t change the order without a doctor’s okay. If the doctor couldn’t be reached right away, there was a delay that could put the patient at risk of developing an adverse drug event, Costa says.

More hospitals now have the nurse check the dose and then follow a standard of care outlined in a prescribed protocol. For example, if the nurse sees a test that indicates the dose is too high or too low she can adjust the order right away--without waiting for a doctor’s okay. That means the patient gets a therapeutic dose of the drug without a potentially harmful delay, Costa says.

Nurses have long double-checked medication orders and performed other tasks that have kept patients safe, Costa says. But now, more than ever, the nurse often serves as the final safety net, someone who can catch an outright error or even a subtle lapse in care. But Costa says nurses must have the resources they need to do the job at hand, a job that includes making sure patients get the right drug at a therapeutic dose.