Published Online: Wednesday, November 1, 2006

The American Society of Health-system Pharmacists (ASHP) is calling on hospitals throughout the country to seek out potential problems in their medication-use systems. Society officials warn that overly complex procedures for storing, prescribing, dispensing, and administering drugs may be contributing to fatal medication errors. ASHP's alert was prompted by a series of tragic hospital medication mix-ups that resulted in the deaths of several premature infants in Indiana.

"This should be a wake-up call for hospitals across the country to be absolutely certain that the right systems are in place to prevent medication errors," said ASHP Executive Vice President Henri R. Manasse, Jr.

According to the association, the medication-use process in hospitals is highly complex and often includes >100 distinct steps, each of which offers numerous possibilities for error and patient harm. "Mistakes such as [the recent drug errors in Indiana] are nearly always the result of a systems failure," Manasse said.

ASHP is recommending that hospitals minimize the number of available concentrations and strengths of high-risk drugs and implement double checks over the process. Additionally, the group is suggesting increasing hospital pharmacy and nursing staffing levels and adopting bar-code technology to reduce drug errors.

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