Diagnosed with a cancerous tumor as a toddler, my two-year-old daughter, Emily, completed her final chemotherapy treatment in 2006 ― and I was elated. My joy quickly morphed into despair when a hospital pharmacy technician mistakenly formulated a lethal dose of concentrated sodium chloride solution.
I was depressed and traumatized when I lost Emily. However, I was not mad at the hospital or the clinician who made the mistake. I knew that the pharmacy technician, who was supposed to use a standard off-the-shelf bag of saline with 0.9 percent sodium chloride, and instead grabbed three vials of hypertonic saline with a 23.4 percent concentration, thought she was doing the right thing but simply made a very human mistake.
Extreme frustration entered into the equation when I began to think about the fact that it was 2006, and we had barcode verification at grocery store cash registers, but not in most hospital pharmacies.
So, my mind immediately started thinking about what could have stopped this error from happening. I zeroed in on one question: “Where did the core systems, processes, and protocols, break down on that horrible day, and how did these lapses set the amazing clinicians up to fail my little girl?" And, I thought that if the hospital just had a barcode medication administration (BCMA) system in place, alarms would have sounded, and my daughter would have been just fine.
Extreme frustration entered into the equation when I began to think about the fact that it was 2006, and we had barcode verification at grocery store cash registers, but not in most hospital pharmacies. With those basic thoughts in mind, I immediately became obsessed with finding ways to prevent what happened to my daughter from happening to other babies and children.
To that end, I have been working for the past ten plus years as the founder, president and CEO, of the Emily Jerry Foundation. With our focus on the elimination of medication errors, I have developed an in-depth understanding of what needs to happen to ultimately improve patient safety.
Here are a few strategies that can help:
- Spare no effort. We need to think critically and truly learn from every medication error that occurs within the healthcare industry, and then subsequently reduce the probability of human error from ever creeping into the equation again during the course of treatment.
- Take a big picture approach. We need to investigate errors with the same holistic approach that is used in other industries. For example, when a catastrophic train accidents occur, transportation authorities don’t automatically assume that it was the engineer’s fault. Instead, they take a deeper look to discover if there was a failure in equipment or processes.
- Require clinically proven technologies. We’ve confirmed patient safety technologies work. For example, when a health system implemented comprehensive IV workflow technology, the accuracy of its sterile IV compounded products immediately increased from 71.7 percent to 99.6 percent. As such, these technologies should not be an option for healthcare organizations, but a required standard of care for all patients.
By mandating the adoption of such technology, we can move toward constructing a system that is purposefully designed to stop inevitable human mistakes before they can do any harm. Most importantly, we can ensure that no child, or any patient for that matter, ever has to experience the fatal consequences that sometimes accompany medication errors. In my opinion, just one life lost due to a preventable medication error is way too many!
The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.