The two bottles were side by side in the refrigerator. One was twice as big as the other. But by mistake, Pharmacist Susan E. Kron apparently pulled out the morphine instead of the heparin.
For three babies in the critical care nursery at Anne Arundel Medical Center, that was the difference between getting the blood-thinning drug that helped to keep their intravenous lines open, and a painkiller that slowed their breathing.
Hospital officials say besides experiencing difficulty breathing, none of the babies was harmed. But the mistake at the hospital is an example of a national problem that experts say kills one hospitalized American every day.
The causes are simple. A doctor's illegible handwriting is misread, an abbreviation is misinterpreted, two similarly named or packaged drugs are confused. Unclear dosage directions can result in too little, too late, or a dose that's too strong. Sometimes a concentrated drug is used in place of a diluted dose.
The results can be tragic. Five years ago in Philadelphia, three infants in the neonatal intensive care unit at Albert Einstein Medical Center died because the pharmacist and pharmacy technician mistakenly added potassium to heparin, the blood thinner. The potassium caused a drop in the babies' heart rates, and they died.
"It's a major problem in hospitals," said Michael Donio, director of projects for People's Medical Society, the country's largest consumer health advocacy organization. In every 100 doses of medication, one error occurs, statistics show. Mr. Donio's group has put together a pamphlet that urges patients to carefully watch the drugs they are given.
In the case of children and infants, that's not possible, and parents can't always be around. And only recently has the U.S. Food and Drug Administration begun to push pharmaceutical manufacturers to define doses for children with their product's labeling information.
Heparin has been a magnet for medication errors in children. That's because drug manufacturers don't make a heparin flush -- a solution injected into the IV to keep the blood vessel from closing -- in the safest dose for children. So pharmacists, and sometimes nurses, must mix the heparin and its diluent themselves, said Michael Cohen, a hospital pharmacist with 25 years' experience and president of the Institute for Safe Medication Practices, which has tracked medication errors for the past 20 years.
