Magazine article Drug Topics

Letters

Magazine article Drug Topics

Letters

Article excerpt

Lesson from patient death: Stay vigilant

In your Sep. 17 issue, I read with sadness and dismay a report about the death of a child at Rainbow Babies & Children's Hospital in Ohio as a result of erroneous administration of a super-hypertonic and concentrated (23.4%) sodium chloride solution, instead of 0.9% sodium chloride as a base solution for a chemotherapeutic medication. With sadness, because a precious life was lost due to an avoidable administration of a potent and fatal solution; with dismay, because the manslaughter charge of the pharmacist involved in the case (if there was no clear intent) would not be a deterrent of future similar mishaps. On the contrary, as correctly pointed out by Michael Cohen, such indictment may "discourage others from reporting errors" of similar or less consequential nature for fear of legal punishment.

There is obviously no easy fix for potential medication errors. For the most part, they are a result of systemic deficiencies. From the broad public point of view, in addition to the legal ramifications, sentinel events of such fatal magnitude may tarnish, perhaps unwarrantedly, the image of not only a particular health worker, be it a pharmacist, a physician, or a nurse, but also a whole profession, a healthcare institution, and by extension the very core of the healthcare delivery system. That is precisely why strict adherence to preventative regulatory guidelines plays a pivotal role in patient safety. The whole mechanism of patient safety is a continuum, an ever-evolving process, especially as healdicare delivery becomes more complex. This sad case behooves all healthcare workers to always be vigilant, even in the face of "rush" and emergency.

Fekadu Fullas, R.Ph., Ph.D.

Sioux City, Iowa

FeFuBal@aol.com

We need one price for all

I agree with Michael Rupp (Viewpoint, Sept. 3) that it is time to overhaul our drug reimbursement system. Since Medicare Part D has been implemented, the number of times I've been forced to fill a prescription at below my acquisition cost has gone up by 700%. It's funny how this never happens with a cash customer. It seems to happen only with third-party plans. We definitely need transparency and we know that the CMS-proposed AMP model is a potential catastrophe. …

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