Sunday Gazette-Mail from Charleston, West Virginia on August 17, 1975 · Page 121
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August 17, 1975

Sunday Gazette-Mail from Charleston, West Virginia · Page 121

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Charleston, West Virginia
Issue Date:
Sunday, August 17, 1975
Page:
Page 121
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Page 121 article text (OCR)

QUARTS, CAL K 17-year-old girl was brought ittfo the City of Hope Medical Center in Duarte, Cal., recently for treatment of asthma. While in the hospital, she developed severe, recurrent pains in her abdomen. Since the X-rays were inconclusive, her physician ordered a chemical test for tumor activity in the intestines. The results were frightening. A reading of 10 would have been normal. The girl's reading was 90, indicating that she had a malignant car- cinoid tumor. An exploratory operation on her intestines seemed inevitable. Dr. Marshall Gilston, a specially trained pharmacist at the Qty of Hope, reviewed the girl's medication record. He found that she was taking an asthma drug that interacted with the chemicals used in the cancer test It produced a misleading result At Dr. Cilston's suggestion, the physician stopped the asthma drug for 36 hours. Then he had the cancer test repeated. This time, it came out absolutely normal. The girl had no cancer. Her abdominal pains were due to a viral infection that cleared up by itself. Patient protection The City of Hope is one of a group of leading hospitals throughout the United States that have established special new systems to protect their patients against dangerous drug mistakes by doctors, nurses and other hospital personnel. The need for such safeguards is critical today. Dr. Allen J. Swartz, director of pharmacy at the City of Hope and a professor of pharmacy at UCLA, told PARADE that more than 100,000 serious errors are made daily in American hospitals in prescribing, preparing and dispensing medications. These mistakes are causing thousands of deaths of hospital patients every year, Dr. Swartz said. "Many patients are dying who don't need to die," Dr. Swartz declared. "In addition, countless hospital patients are not recovering as fast as they should because, through somebody's error, they are not receiving the proper medications for their condition." Dire results The big problem is that many physicians are inadequately trained in the use of drugs. According to experts in the field, the average doctor is familiar with only a tiny percentage of the 7000 principal drugs in the medical arsenal. As a result, some doctors prescribe the wrong drugs, the wrong dosage, or the wrong method of administering it They often prescribe drugs that interact hazardously with another drug. Many nurses are as guilty. They write down doctors' orders incorrectly or make careless mistakes In carrying them out. They give medications to one patient that are meant for another patient Some hospital pharmacists make errors in filling prescriptions. In the course of a nationwide investigation, PARADE encountered case after case of tragic drug mistakes in hospitals. by Donald Robinson City'of Hope Medical Center in Ca//forn/a has begun a program to help prevent medication errors. Pharmacists there not only dispense drugs but a/so answer drug-re/ated questions of patients and advise doctors on their prescriptions. Here pharmacist Marsha// Ci/ston talks with a patient. For example: · A physician in one Midwestern hospital made a mistake in his arithmetic and directed a nurse to give a middle-aged man 10 times the recommended dosage of an extremely toxic anti-cancer drug. It cost the patient amputation of his leg. · A nurse in a New York hospital accidentally switched two unlabeled hypodermic syringes on her medication cart She administered an injection of penicillin to a woman patient who was highly allergic to the antibiotic The woman almost choked to death. · In a well-known West Coast hospital, a prominent surgeon was performing an abdominal operation on a young woman. Toward the end of the procedure, he ordered the wound washed out with an antibiotic solution. He didn't know that the antibiotic interacted with the curare-type anesthesia the patient had received to depress her breathing. The antibiotic depressed the patient's breathing still more and she went into respiratory arrest In two minutes she was dead. Nothing the operating room team did could revive her. They are far from isolated cases. A long-term investigation into the drug setup of a famous university hospital in the South was conducted by five experienced medical researchers. They discovered that drug errors of commission reached a rate of nearly 21 per cent The national rate may be much greater because many drug mistakes go unreported. An investigator who made a widely heralded study of medication errors at a University of Florida teaching hospital estimated that "something on the order of 51,200" major and minor medication errors probably occurred in that one hospital during the year the study was underway. Yet only 36 official reports of drug errors were filed in the entire period by the hospital people involved. The City of Hope, a hospital specializing in catastrophic diseases, has launched an intensive campaign to eliminate medication mistakes. It has instituted a far-reaching four-point program: 1. No City of Hope pharmacist is al- lowed to dispense any drug until he is given a copy of the physician's drug order in writing. This is a much more radical step than it sounds. Surprising to say, the vast majority of hospitals in the United States does not take such a precaution. According to Dr. Swartz, in 90 per cent of the country's hospitals, a nurse or a ward clerk can order any drug she wants by telephone, or walk into the hospital pharmacy and ask for it The pharmacist sees nothing in writing. "With no copy of the doctor's order to check against," Dr. Swartz said, "if s a very risky situation for the patient, and we won't tolerate it" New system 2. To cut down on drug errors by nurses, the City of Hope has installed a revolutionary new "unit dose system." In most hospitals, drugs are dispensed in bulk containers to each nurse, and she stores them in her own drug closet When the hour comes for her medication rounds, the nurse usually counts out the pills for each patient into unmarked paper cups, and fills unmarked hypodermic syringes. As a rule, no medication on the cart bears a label stating what it is or for what patient it is intended. The nurse trusts her memory. "And let me warn you that a nurse's memory can betray her," Dr. Swartz said. "She may get a telephone call while she is making her medication rounds, or she may be interrupted by an emergency with a patient," he explained. "By the time she gets back to her medication cart,, it is difficult for her to tell which medication is which." Under the "unit dose system," all medications are dispensed by the hos- pitaLpharmacy in individual units of use such as one injection in a disposable syringe, one liquid dose in a disposable bottle, or one tablet in a foil package. Each item is fully labeled as to its identity and strength. The pharmacist's check Every morning, a City of Hope pharmacist--not a nurse--checks each patient's chart to see what medications he is to receive that day. The pharmacist then places the precise number of unit doses in a separate drawer in the nurse's medication cart that is cieariy marked with the patient's name. 3. As an extra safeguard, the City of Hope has set up a chain of satellite pharmacies throughout the hospital, m addition to the central pharmacy, there now is a well-equipped pharmacy close at hand for every 35 patients, with a clinical pharmacist on duty who knows the drug needs of each patient 4. The final point in the City of Hope program, and the most important, is its corps of clinical pharmacists. They are an entirely new type of pharmacist. An ordinary hospital pharmacist spends most of his time filling prescriptions. A continued

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