Prescription Errors: A Simple Mistake Can Cost Lives
Every year, thousands of people suffer injuries, and some even lose their lives due to mistakes in prescription medication dosing. One major culprit is the tenfold error, where an extra zero is mistakenly added, causing the patient to receive ten times the intended dose.
How Prescription Errors Happen
Mistakes with prescriptions can happen at any point, from the doctor’s initial order to when the patient actually takes the medication. Some errors involve confusing similar-sounding drug names, while others stem from misinterpreting dosing abbreviations. Thankfully, many of these errors are minor and get resolved quickly without serious harm. However, tenfold errors, often referred to as “zero errors,” can be extremely dangerous.
Case in Point: Dennis Quaid’s Newborns
In 2007, a high-profile case brought tenfold errors into the spotlight. Actor Dennis Quaid’s newborn twins were accidentally given 10,000 units of the blood thinner heparin, rather than the prescribed 10 units. This wasn’t an isolated incident. A study by the US National Institutes of Health on 200 cases of tenfold medication errors found that 45% had severe consequences.
Understanding Tenfold Errors
These errors mainly occur when an extra zero is added, making a prescription for “55.0 mcg” read as “550 mcg.” The reverse can happen too, where a zero is left out, resulting in a much lower dose than needed. Misplaced decimal points or unnoticed decimals can turn “.55 mcg” into “55 mcg.” Confusion between dosages for different forms of a drug, like tablets versus liquids, can also lead to tenfold errors.
Preventing Mistakes
To combat these errors, experts recommend always placing a zero before a decimal point, such as writing “0.10 mL” instead of “.10 mL.” Avoiding trailing zeros, like writing “25” instead of “25.0,” can also prevent confusion.
While prescription errors can happen at any stage, those involving extra zeros or misread decimal points usually stem from the prescribing process or the healthcare professionals administering the medication. The potential for severe consequences underscores the importance of being vigilant in managing prescriptions at every step.