Medication errors blamed on handwriting, tired nurses

A CBC investigation into medication errors in Winnipeg's hospitals shows most of the mistakes happen at the administration level, when nurses take the medication out of drawers or cassettes and give it to the patient at the bedside.

In the past five years, there has been a dramatic increase in the number of medication errors at Winnipeg's two largest hospitals, the Health Sciences Centre and St. Boniface General Hospital.

• April 14, 2003: Medication errors increase at city hospitals

The most frequent medication errors at all city's hospitals involve giving a patient the wrong dose, forgetting to give a dose entirely, or giving the wrong medication.

"People are human. People can get distracted. They pick up the drug out of cassette A, which should be going to patient A, and somehow they get into patient B," says Wolfgang Peppel, site manager of the pharmacy at the Grace Hospital.

"Those things happen. Doses are omitted. It could be that the drug isn't up there in a timely fashion. It could be that nurses were called away, that there was a crash somewhere. There's 101 reasons why that could occur."

Nurses believe the critical shortage of staff is having an impact on the number of medication errors and incidents. They say working overtime and doing double shifts, results in fatigue, and fatigue can lead to mistakes.

Bad handwriting no joke

Another area where mistakes are common involves the prescriptions themselves. Jokes are often made about doctors' handwriting, but the legibility of a physician's handwriting in ordering prescriptions can result in medication errors.

Dr. Margaret Brunt, a specialist in internal medicine at the Health Sciences Centre, also sits on a regional committee that has a mandate to address the overall problem of medication error in the system. She says all kinds of mistakes can be made if the nurse, the pharmacist or the unit clerk can't read what the doctor has written.

"The legibility of the handwriting is a major issue," says Brunt, who sits on a regional committee addressing the overall problem of medication errors in the health care system.

"As you know, many drugs have similar names. When those names are written in a way that is unclear, then that is a potential focus for error. Transcribing the error would relate somewhat to the handwriting issue."

A January 2003 report on incidents at all Winnipeg hospitals shows illegible handwriting as the top cause, with 175 incidents, followed by unclear or wrong directions, with 146 incidents. Below that are incidents in which the order was faxed twice, and cases where the dose was missing, unclear, or wrong.

• See the report (PDF file)