It could happen to anyone...

Originally posted 8-23-2010:
Sometimes a real life story is the best way to drive home the importance of preventing medical error.  It puts a face on the patient safety issues and serves as a reminder that these errors have an effect on someone's life.  I have noticed that there is a stronger response when a medical error is looked at from a patient or patient's family point of view.  This is why Dennis Quaid has been acting as a patient safety advocate for the last few years.  The story of his twin daughters being subjected to a dangerous heparin overdose in now one of most well known patient safety stories.  A story not only identifies a potential patient safety issue, but it gets an emotional response out of people that can drive the desire to make a change.

I recently noticed how the story behind a medical error can have a stronger impact when you know the person affected.  A friend told me last week that he realized that a pharmacy gave him the wrong dose of a antibiotic.  The prescription was due to a sinus infection he was suffering from.  He noticed the infection was not actually getting better, but instead lingered causing him to miss a lot of work and just continue to live in misery.  After some investigation, he found out the prescription was correct but the error occurred in the pharmacy.  This was not a life threatening situation, but there was a temporary reduction in quality of life and productivity for him.  In addition, this is the sort of thing that can cause increased bacterial drug resistance.  I can only imagine what sort of effect this could have had if the medication had a more critical purpose.

I suggested to my friend that he go back to the pharmacy to let them know what happened, otherwise they will never be aware and learn from the mistake. The pharmacy needs to evaluate its system, find the root cause, and develop a solution to avoid this sort of wrong dosing error from occurring again. This also shows how important it is for patients to keep track of their own care.  Patients can provide the final piece of feedback to make sure the proper treatment is made.