This past September Hospira was approved for a heparin product that features, according to its web site, an ‘enhanced label design.’ Among the features of the label design are, “vibrant label colors to each strength, simplified text and increased font for dosing information, and differentiated warning labels”.
Sounds pretty basic. A hospital is a high-stress environment. Decisions have to be made quickly and accurately with split-second timing. Often there are parents, or loved ones in the room panicking. And while doctors and nurses are trained to focus on the task at hand and resist becoming distracted by any outside force that may take away from the direct relationship between practitioner and patient, the fact remains that people are human and things can get confusing.
Thus, the labeling of medication in such an obvious fashion as to ensure that the wrong medication, or strength is not fed to the wrong individual seems pretty obvious. In a quiet room without distraction a practitioner has the opportunity to carefully size up the vial and the label before injecting the substance into his patient.
However hospitals—and especially the ER—are far from quiet. There are a thousand-and-one things going on at once as you reach for that vial. Did I check the label? Oh, I’m sure I did. This is the right stuff…
For Kimberly and Dennis Quaid, it turned out to be the wrong stuff. Read the rest of this entry »