Pharmacy Times, Volume 0, 0

The American Society of Health-systemPharmacists (ASHP) is callingon hospitals throughout the countryto seek out potential problems intheir medication-use systems. Societyofficials warn that overly complexprocedures for storing, prescribing,dispensing, and administeringdrugs may be contributing to fatalmedication errors. ASHP's alert wasprompted by a series of tragic hospitalmedication mix-ups that resultedin the deaths of several prematureinfants in Indiana.

"This should be a wake-up call forhospitals across the country to beabsolutely certain that the right systemsare in place to prevent medicationerrors," said ASHP ExecutiveVice President Henri R. Manasse, Jr.

According to the association, themedication-use process in hospitalsis highly complex and often includes>100 distinct steps, each of whichoffers numerous possibilities forerror and patient harm. "Mistakessuch as [the recent drug errors inIndiana] are nearly always theresult of a systems failure," Manasse said.

ASHP is recommending that hospitalsminimize the number of availableconcentrations and strengthsof high-risk drugs and implementdouble checks over the process.Additionally, the group is suggestingincreasing hospital pharmacyand nursing staffing levels andadopting bar-code technology toreduce drug errors.