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Power outage leads to scrambled drug labels
Duke CEO pledges hospital will become safety leader
Report: Care complications follow patients home

Patient Safety Monitor Alert, March 25, 2003

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POWER OUTAGE LEADS TO SCRAMBLED DRUG LABELS

Drugs and darkness: Not a great recipe for patient safety, it turns out. A power outage earlier this month left Kaiser Permanente computer center in the dark and also caused havoc to the drug orders of approximately 4,700 patients.

Due to the power outage, some drugs were labeled incorrectly, affecting both patients who had their prescriptions filled at Kaiser's 108 Northern California pharmacies and those who ordered prescriptions over the telephone, according to abcNEWS.com. Even if the information printed on their prescriptions was correct, patients still could have received the wrong drug, a hospital spokesperson told reporters.

Hospital officials discovered the errors a day later and tried to contact patients to warn them about the labeling error. However, they weren't able to reach everyone. Four days after the improperly labeled drugs were distributed, officials still hadn't contacted 152 patients who may have received the drugs. Fortunately, no reports of adverse drug reactions due to the errors had been reported at the time the article was published.

DUKE CEO PLEDGES HOSPITAL WILL BECOME SAFETY LEADER

Duke University Medical System plans to learn from its mistakes. Following a nationally publicized organ transplant-mixup at the hospital, Duke's chief executive officer announced that he will use the experience as a "springboard" to move the hospital to a leadership position in the patient safety movement.

The hospital will use the lessons it learned when 17-year old Jesica Santillan was mistakenly given a heart and lung of the wrong blood type to become "a strong voice to improve the safety of transplantation," Ralph Snyderman told the [Durham, NC] Herald-Sun.

Due to the error, Duke's status was downgraded last week from "Accreditation with Full Standards Compliance" to "Accreditation with Requirements for Improvement," by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), according to a memo posted on the University's medical news Web site (www.dukemednews.org). Duke plans to respond to the JCAHO's inspection report and provide the accrediting agency with a statement of corrective actions.

REPORT: CARE COMPLICATIONS FOLLOW PATIENTS HOME

The road to home is paved with medical complications, a recent study has found. Nearly one in five patients discharged from a large teaching hospital suffered an adverse event following discharge from the facility, according to a February article in the Annals of Internal Medicine. Of the 400 patients studied at the unnamed hospital, 76 experienced adverse events after they were released from the hospital. Twenty three of those events were considered preventable.

According to an article in the Seattle Times, some of the events include
- serious diarrhea (from medication)
- severe dehydration
- a fall that caused rib fractures
- infections

Better communication, planning and systems at the hospital could have helped avoid many of the problems, researchers told the Times.

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