Why do we care about accuracy?

1
Why do we care about accuracy?

• A lawyer writes The plaintiff should recieve
  10,000 in damages.
• Has anyone been physically harmed by this
  spelling error?
• How about these?

2

• A nurse writes on a patients chart X-ray
  requested of the ileum. When she means ilium.

3

• A doctor writes qid on coumadin prescription
  instead of qd.
• The patient takes the medication 4 times a day
  rather than once a day . . .
• . . . and dies of internal bleeding.

4
Why do we care about accuracy?

• A pharmacist fills a prescription for Dioval
  (estradiol) with Diovan (high BP).

5
Dont all doctors have messy handwriting? Who
cares??

• This prescription for Isordil was read by the
  pharmacist as Plendil.
• The patient died of a heart attack.

6
In the News. . .

• July 2006 - Madison, WI
• Nurse administers epidural anesthetic instead of
  penicillin to 16 year old girl.
• The girl dies.
• Nurse received 3 years probation/suspension for
  wrongful death

7
In the News. . .

• Nov. 2007 - Los Angeles, CA
• Dennis Quaid case
• Newborn twins treated with 10,000 units/ml
  heparin vs. 10 units/ml
• Drug company had new labels - but didnt recall
  the old.

8
In the News. . .

• December 2007 - Nashville, TN
• Prednisone overdose
• (3 days of 1250mg vs 250 mg)
• causes kidney transplant failure

9
In the News. . .

• July 2008 - Corpus Christie, TX
• 17 newborns overdosed with Heparin
• 2 die