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Three Names to Remember

D’myia Alexander Nelson, Emmery Miller and Thursday Dawn Jeffers didn’t have much chance. After receiving adult dosages of the blood-thinning agent heparin, the three premature newborns died in an Indianapolis hospital in September. Apparently a pharmacy tech had stocked a cabinet with vials containing an adult dose that was 1,000 times stronger than what newborns should receive, according to The Associated Press. The administering nurses did not notice the misplaced vials, which are hard to distinguish from the pediatric doses, the AP reported. The resulting deaths of the three infants at Methodist Hospital created national news and unspeakable anguish for the families.

The deaths also put a face on a national problem. It has been exactly seven years since the Institute of Medicine issued its groundbreaking report, To Err is Human. The report estimated that as many as 98,000 people die annually in hospitals because of medical errors. Some observers have challenged the IOM conclusion as exaggerated.

Nevertheless, the study sparked major interest in using information technology as a tool to safeguard patient safety. I can’t tell you how many times I have heard the rounded-up “100,000 deaths” figure blithely tossed out during presentations. Even though it is an extrapolated estimate, the number has become a symbol of why IT is so sorely needed in care delivery. Particularly in the realm of medication administration, technology can help overcome the “human and procedural errors” that Methodist Chief Executive Officer Sam Odle cited as contributing to the deaths of the infants.

In reporting this issue, I visited Aurora Health Care in Milwaukee, where preventing medical errors has been a key driver in a major electronic medical record initiative. Years in the making, the project testifies to the difficulty of automating care delivery. One goal, explains Judy Murphy, the vice president of information services, is a “closed loop” in medication administration. Simply put, IT will support the delivery of medications during the sequence that begins with ordering, moves through pharmacy, and concludes at bedside.

It’s a complex chain that is difficult to automate. But now, on top of an abstract number, we have three names to remind us how important such undertakings are. They are D’myia Alexander Nelson, Emmery Miller and Thursday Dawn Jeffers.

—Gary Baldwin




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