Maryland Pharmacists Warn of Anticoagulation Medication Errors

The Maryland Pharmacists Association Newsletter for November, 2008 reported that in the last seven years, in hospitals alone, anticoagulation medication errors occurred in 70,000 instances. In twenty-six of those instances, the patient died. The report goes on to state that “[h]eparin and warfarin are consistently ranked among the 10 most frequently reported drugs involved in errors.” (Warfarin is the generic name for the better known brand name drug, Coumadin.)

When I read this article, I was surprised and concerned that such a potent drug – a blood thinner – given in too high a dose can cause a deadly hemorrhage, and that given in too low a dose might fail to prevent the formations of blood clots that the drug is designed to prevent, is so regularly dispensed by hospitals improperly.

I am interested to learn the names of the other medications that are most commonly misfilled by hospital pharmacies. Are they pain medications, like oxycodone or morphine, insulin injectables that can provide treatment in a rapid onset or an intermediate duration, or antibiotics that combat specific infections?

A doctor in Baltimore once told me: “Hospitals are dangerous places.” Add hospital pharmacy errors to the list of dangers.


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