Preventable Medical Errors – The Sixth Biggest Killer in America How many Americans work in the field of healthcare? Healthcare sector is our fastest growing employment sector; 1 in 8 American’s currently work in healthcare. That is about 39 million people! In May 2013, The Economist published an article called The Health Paradox. The topic, “America’s rampant health spending threatens its economic future. It also supports tens of millions of jobs” ALL of these occupational paths work exclusively in the modern metric system! How big is the problem? About 1.5 million preventable “adverse drug events” occur in the United States every year, according to a 2007 study by the Institute of Medicine, part of the National Academy of Sciences. What are the financial costs? The annual cost of medical errors that harm patients are estimated to be $17.1 billion (Milliman Inc study, 2011), while medication errors cost the U.S. $4 billion a year (Institute of Medicine, 2007). How does teaching customary units in schools impact the quality of healthcare in the United States? Healthcare demonstrates the most dangerous consequence of perpetuating the misalignment between how we educate our children to “intuitively” think about measurement (in customary units) and how healthcare professionals are required to function (in the metric system). What are the two most common conversion-related medication errors? Example 1: Doctor Office/ Hospital error: A Weighty Mistake (Doctor Office/ Hospital error) A toddler is taken to the emergency room (ER) and, as is custom, the triage nurse tells the parent that the child’s weight in pounds- 25 pounds to be exact. When the nurse enters the data into the computer, she is supposed to convert the weight to kilograms. Twenty-five pounds is about 11.3 kilograms. However, when the triage nurse enters “25” into the computer system, the system assumes it is kilograms and the toddler is now charted at weighing 25 kilograms. Consequently, the toddler is prescribed medication based on a mass 25 kilograms instead of the correct 11.3 kilograms. This is more than double the recommended dosage. Errors like this occur daily in the United States, because our medical professionals did not grow up learning the preferred language of medicine—the metric system. This leads us to the next consequence of our educational misalignment—the lack of number sense as it relates to metric units. During the ER visit in the example above, many medical professionals examined the toddler—nurses, a medical resident, and a doctor—but no one had the “number sense” to recognize the weight error. In any other country, all of these professionals would have looked at the young, small toddler and known intuitively that the baby was far smaller than 25kg! This is a uniquely American issue. Because of our traditional K-12 education system and our consumption habits, 25kg is just an abstract concept. In order to prevent these easy yet often fatal mistakes, our medical professionals need to grow up learning the language of medicine—the metric system. Example 2: Pharmacist error: A Teaspoon is NOT a Milliliter (Pharmacist error) According to The Institute of Safe Medicine Practices (ISMP), this conversion error mistake is more common because it happens in both hospital settings and more frequently at the point of sale—the pharmacy. It is a conversion error because the mistake is made when converting milliliters from the prescription to teaspoons on the medication bottle. A child who recently had surgery was seen in an emergency department and was later admitted with respiratory distress following an unintentional overdose of Tylenol #3 (acetaminophen and codeine). The pharmacy-generated label on the child’s medication bottle instructed the parents to give the child 6 teaspoonfuls of liquid every 4 hours. However, the original prescriber stated the prescription was for 6 mL. The child received 5 times the recommended dose before arriving at the emergency department. In a second case, a child received an overdose of the antifungal medication Diflucan (fluconazole) suspension. The physician phoned a prescription for Diflucan 25 mg/day to a community pharmacy for a 3-month-old child with thrush. The pharmacist dispensed Diflucan 10 mg/mL. The directions read “Give 2.5 teaspoons daily.” The directions should have read “Give 2.5 mL daily.” When teaspoons are confused with milliliters, the result is five-fold overdose (one teaspoonful is approximately equal to 5 mL). Unfortunately, most parents also lack a basic understanding of metric units; therefore, after seeing and in most cases being instructed of the correct dosage in milliliters, most parents still do not understand that a teaspoon is NOT a milliliter. ISMP first reported on the confusion between teaspoonfuls and milliliters (mL) in its newsletter in 2000, and issued a call in 2009 for practitioners to move to sole use of the metric system for measuring over-the-counter (OTC) and prescription oral liquid doses. However, mix-ups have continued to result in the serious injury of children. As ISMP has received more than 50 VOLUNTARY reports of mL-teaspoonful errors, the true number is much greater. For more information, read ISMP Statement on Use of Metric Measurements to Prevent Errors Which other organizations are concerned? All of them!!! All professional healthcare associations and all federal organizations such as the Food and Drug Administration, Consumer Healthcare Products Association, and Centers for Disease Control promote the exclusive use of the metric system in all aspects of healthcare. Many for-profit companies, including McNeil Consumer Healthcare, are moving in this direction by standardizing their acetaminophen infant and children’s oral liquid medications in a single concentration and developing dosing devices that measure in mL. States are also aggressively working to reduce preventable medication errors in pediatrics. Arizona is the most recent state to “go metric.”
