Circulation 84,122 • Volume 23, No. 3 • Fall 2008   Issue PDF

Errors Difficult to Completely Eliminate

Howard Schranz, MD

To the Editor

Dr. Workhoven is of course correct that no one should ever administer a medication based on color or shape clues without reading the label. However, it is unrealistic to predict that using words alone, written or spoken, will prevent all drug error.

Many drug names look alike (e.g., hydralazine and hydroxyzine, amrinone and amiodarone), especially if your reading glasses are smudged. The words even sound alike, when spoken in noisy operating rooms, especially those wired with the kind of hard-rock soundtracks favored by orthopedic and chest surgeons. The spoken word can also be misunderstood when expressions like “the bolus,” “the antibiotic,” or “start 2 of epi” are used.

Real life does not end at the operating room (OR) door, and misunderstandings will never end—despite our best efforts. The only solution I can envision is the development of a new type of OR specialist who checks every medication before it is administered and confirms the identity of every vessel before it is ligated

Howard Schranz, MD
New York, NY