Learning from mistakes, the hard way

Medicine | Three preemie deaths reveal the dark side of medicine: Health-care workers are human, too | Lynde Langdon

Name mixups are often embarrassing but sometimes can be fatal. Nurses and pharmacists at Methodist Hospital in Indianapolis killed three babies due to human error last month. Hospital personnel routinely dispense a drug called heparin to "flush" intravenous lines and prevent blood clots in the IV catheters. At Methodist Hospital, a pharmacy tech accidentally stocked a few vials of adult-dose heparin in the neonatal ICU. The highly concentrated medicine killed three of the six premature babies who received it in one day, despite the fact that the adult vials were labeled differently than infant-safe drugs.

The Institute of Medicine, a government-commissioned, independent advisory agency, estimates that more than 450,000 medication errors occur every year in U.S. hospitals. Not all those errors kill someone, but they all make people sicker. (About 7,000 cause patient deaths.) The mistakes range from oversight, such as hospitals not asking patients about their allergies before dispensing medicine, to ignorance, such as a pharmacist not asking a doctor to clarify illegible handwriting.