02 - Lethal Injections

Shari Welch, MD, FACEP

According to the IOM there are more than 100,000 deaths per year due to medical errors. Healthgrades estimates that the numbers are even higher! Four per cent of hospitalized patients suffer an adverse event which extrapolates to a million injuries a year! One fifth of these are medication errors.

According to a number of international studies, we get it right in medicine only 80-90% of the time. What can be done in the emergency department to improve on these statistics? The first step is to recognize that humans do err, and they do so frequently, predictably and regularly. In the IOM report TO ERR IS HUMAN for the first time the profession acknowledged the limits of human performance. This is an important acknowledgement, for if we do not take note of this reality and build our work flow and processes to compensate for our errors, we will never manage them. On the other hand, by changing the culture to encourage the identification of errors and then adapting the system to compensate, we may eliminate many of the errors or at least compensate for them and mitigate the consequences.

Potassium Chloride is one of the most dangerous drugs we carry in an emergency department. Numerous deaths have been reported due to accidental overdoses either by infusing too much too quickly due to incorrect preparation and calculation or by accidentally grabbing the vial in lieu of another medication. This error is fatal (remember we use this for lethal injection in capital punishment cases!) and many patient safety experts have come to feel this drug has no place in an ED where human error can lead to a fatality. Many health systems have taken it out of dispensing systems and med room altogether and have potassium drips pre-made in the pharmacy where standardization has lead to improved safety. Shouldn’t you set this up with your pharmacy, today?