Dennis and Kimberly Quaid endured a medical catastrophe no family should ever experience.
Last week, actor Dennis Quaid testified before the U.S. House Reform and Government Oversight Committee, recalling the harrowing, near-fatal events that unfolded after his newborn twins were mistakenly given a medication overdose. The Quaids’ story puts a human face on medical error.
When I was a young nurse, I saw a 4-year-old hospital patient die as a result of a medication error. The parents grieved, the hospital staff followed the entrenched cultural norm of never discussing it, and the nurse who felt responsible went home that day and never returned — abandoning a career she was good at, and loved. We were all haunted by that tragic mistake. I remember thinking there had to be a better way.
Fast forward a few decades to a new study published this month in the journal Pediatrics. The authors found that for every 100 children admitted to hospitals, there were about 11 drug-related harmful events — more than one in five of which were preventable. My reaction this time was far different from my reaction to the 4-year-old’s tragic death. This time I felt a mix of resolve and humility. I was gratified that this kind of patient safety research is being conducted in a pediatric setting, humbled by the knowledge that harm continues in the delivery of care, and committed to preventing adverse events in our youngest patients.
An almost seismic shift
What’s changed? An almost seismic cultural shift that recognizes the importance of acknowledging and tracking medical errors, but one that believes harm-free care is achievable. In 1999, Children’s Hospitals and Clinics of Minnesota began to build a patient-safety culture grounded in the belief that to err is human and these errors can serve as an important data source to help us learn to provide harm-free care.
As the chief operating officer charged with leading this effort, I realized that to create this kind of cultural shift, it was essential to engage the most senior leaders of the organization — including our CEO, the board and professional and clinical staff. The commitment to safety had to permeate throughout the organization. We all had to believe we could achieve zero harm to patients.
We took on medication errors first, making prevention the core of our patient-safety strategy. In all care settings, nearly three out of four medical errors are related to medication. The risk is high for children because medications are often tested and developed for adult populations, thus making dosage calculations necessary and medicine dilution frequent. We took an “inch-wide and mile-deep” approach to reviewing each category of errors so that we could map the underlying systemic fault lines. We wanted understanding for prevention, not a place to point fingers.
A review of medication practices showed that medication errors were often due to human error. For instance, the risk of overdose is far greater when you leave out the zero in front of a decimal point (“.125 mg” vs. “0.125 mg”), or when your prescription is vague or based on the wrong measurement units (“two tablets” of unspecified strength vs. “500 mg”). People err, and systems must be built to protect against this.
Look-alike labels replaced
We’ve learned that patient safety requires vigilance and rigor that cannot cease. In the case of medication errors, our safety action teams, specialty groups within the hospital, constantly assess and study the potential impact of a new medicine, including its label for opportunity for error. We have replaced look-alike and sound-alike labels with visually distinctive ones — a concern raised in the much-publicized medication error involving the Quaid twins.
When Children’s nurses noticed possible confusion between two syringes used to give insulin injections to children with diabetes, they issued a Children’s-wide safety alert to explain the differences between the syringes and separated the syringes from each other.
We are highly committed to achieving a harm-free hospital. But all of us in the national patient-safety community agree we have far to go. Pediatric research lags behind the major — and remarkable — increase in research on adult patient safety.
While the new study shows some effective tools for reliably detecting potential errors in medicating children, it also highlights how little research has been done in the area. We need to start filling that void, and fast.
Julie Morath, RN, MS, is the chief operating officer and vice president of care delivery of Children’s Hospitals and Clinics of Minnesota. She is a member of the steering committee of the National Quality Forum, a board member of the National Patient Safety Foundation and an author of two books on safety and quality in health care.
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