27 September 2002

Medical Error: The Wrong Patient

I was an Air Force fighter pilot for 11 years and experienced the loss of many of my fellow pilots in Vietnam and elsewhere. A serious aircraft incident was almost always the result of several errors in a sequence which compounded one another. Almost never does a single error cause a major catastrophe. The same is true in medicine.

The Wrong Patient
Mark R. Chassin, MD, MPP, MPH; and Elise C. Becher, MD, MA*
Ann Intern Med. 2002;136:826-833.

Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

14 September 2002

Clark Zapper Inhibits Growth of Leukemia Cells

Many people working with electromagnetic frequency devices, whether Rife or FSCAN devices, know that growth of cancer cells is selectively inhibited by the right frequencies. Dr. Lai and his research group, at the University of Washington, has demonstrated this in cell culture with a Clark Zapper which only puts out a single frequency.

Low-intensity electric current-induced effects on human lymphocytes and leukemia cells

Narendra P. Singh and Henry Lai
Department of Bioengineering
University of Washington
Seattle, WA

The purpose of this study is to investigate whether low-intensity current affects cells in culture. Two types of human cells: white blood cells (lymphocytes) and leukemia cells (molt-4 cells), were studied. A low-intensity time-varying electric current (0.14 milliamp) generated by the Clark Zapper was applied to cell cultures via two platinum electrodes for 2 hrs at 37o C. Cell counts were made at different times after electric current application. Results show that the current had no significant effect on human white blood cells up to 24 hrs after exposure, whereas it significantly inhibited the growth of leukemia cells. At 24 hrs after exposure, concentration of leukemia cells exposed to the electric current was only 58% of that of non-exposed leukemia cells. These data suggest that the electric current can selectively inhibit the growth of leukemia cells and does not significantly affect normal cells. A manuscript describing these results is in preparation for publication. In addition, the same electric current exposure (0.14 milliamp, 2 hrs at 37oC) was applied to E. coli bacteria cultures. No significant effect of the current was observed in E. coli cultures at 24 hrs after exposure.

Further research should investigate whether this selective electric current-induced growth inhibition also occurs in other types of cancer cells. The critical current parameters and mechanism of this effect should also be investigated.

09 September 2002

Medication Error: Almost 20% of medications given in hospitals are the wrong dose

Medication Errors Observed in 36 Health Care Facilities
Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette A. Pepper, PhD; David W. Bates, MD, MSc; Robert L. Mikeal, PhD
Arch Intern Med. 2002;162:1897-1903

Background: Medication errors are a national concern.
Objective: To identify the prevalence of medication errors (doses administered differently than ordered).
Design: A prospective cohort study.
Setting: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.

Participants: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.

Methods: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.

Main Outcome Measure: Medication errors reaching patients.

Results: In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04)

Conclusions: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.