New system warns health professionals of medication errors

E-mail alerts will describe the error and provide recommendations to prevent a similar mistake.

By — Posted Jan. 15, 2010

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With the December 2009 launch of a new national e-mail alert system for medication errors, health care professionals nationwide will get quick notice when a deadly or potentially deadly error has occurred.

The Institute for Safe Medication Practices and the American Society of Health-System Pharmacists teamed up and developed the National Alert Network for Serious Medication Errors.

Initially, alerts will go to the 35,000 pharmacists and other health care professionals in the ASHP network and ISMP's newsletter network, which reaches representatives in every U.S. hospital. But the goal is to extend the effort with the help of more national organizations, said Mike Cohen, CEO of ISMP.

The alerts will include a description of the error and recommendations to prevent the same type of mistake. They will be sent only for the most dangerous types of medication errors, possibly fewer than 10 times a year, Cohen said. ISMP officials will determine whether to send an alert.

He gave an example of what would trigger an alert: In 2008, the concentration of Fer-In-Sol pediatric oral iron drops was reduced by the manufacturer, Mead Johnson, but the news was not widely spread to update pharmacy computer records or drug indexes. Doctors who were unaware that the concentration had changed prescribed the same amounts, and patients didn't get enough iron.

The bigger problem came when pharmacists who got a correct prescription reached for generic versions of the liquid still on the shelves, which had the old concentration, and patients got too much iron, Cohen said.

"It's a dangerous situation. Pediatricians were not informed. Hospitals were not informed. ... That's the kind of thing that would rise to the level of needing a national alert," Cohen said.

Information in the alerts will come from several sources, including voluntary reporting and news reports. When the information is not obtained through public resources, the alerts will not identify the hospital, patient or health care professionals involved in the error. Alerts will be archived and available to the public on the ASHP Web site.

The system stems from the ASHP's 2008 I.V. Safety Summit, which focused on ways to end medication errors, such as the one that seriously harmed actor Dennis Quaid's twins. In November 2007, the then 2-week-old infants, being treated for a staph infection, were given 10,000 units of heparin instead of the 10-unit dose for babies.

Urgent and widespread notification for all health care professionals sets this alert system apart, Cohen said. He said that when a large volume of people are made aware of errors though the system, "it will make it harder for product manufacturers to minimize them."

"We're not going to be able to prevent all the events, but I think we will be able to prevent a significant number more than we have in the past," Cohen said.

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