The Truth Is, Patients Are Safer Today Than 20 Years Ago

摘要

It has been a privilege to be able to communicate with members of INS for more than 25 years through my medication . safety column in INS' bimonthly newsletter, Newsline. You and your nursing colleagues have shared many accounts of medication error-related problems. Some were profoundly tragic. Discussions like those featured in Newsline, the Journal of Infusion Nursing, and other publications have had a significant impact on overall patient safety. In many cases, and sometimes with prodding, regulatory authorities such as the US Food and Drug Administration, standards organizations such as United States Pharmacopeia (USP) and The Joint Commission (TJC), and medical product manufacturers have recognized the serious nature of these discussions and reacted. Improvements have resulted. The good news is that many serious medication errors we talked about over the past 25 years are predominantly problems of the past, and our patients are safer for it. Let me provide an example. In the 1980s and 1990s, we discussed tragic errors involving potassium chloride (KCI) concentrate vials, which were commonly stored on hospital nursing units for preparation of intravenous (IV) admixtures. Mental slips were occurring: Nurses somehow were converting an order for furosemide (Lasix) injection, which causes potassium loss, and instead were administering KCl concentrate injection. More than once, an IV potassium bolus was administered instead of Lasix. Patients would scream in pain, lunge backward in bed, and go into cardiac arrest. Resuscitation failures and fatalities resulted.