Drug Labeling and Tamiflu Dosing Errors
Miranda Capra / Human FactorsLast month, the FDA issued a public health alert about Potential Medication Errors with Tamiflu Oral Suspension. Doctors in the US typically prescribe dosages for liquid drugs in terms of teaspoons. However, the eye dropper that comes with the medication has doses listed in milliliters. Users that do not realize this difference might under-dose themselves, leading to not being protected from the flu, or over-dosing, which could be potentially fatal, especially for young children. Now that doctors are aware of this problem they can issue dosages in milliliters, assuming that the doctor is able to properly do the conversion math. The best way to solve this would be to have the US using the same measurement system as the rest of the world, but that’s a huge issue all to itself. The next best solution is to have drugs that use the local units, or at least be labeled with both metric and English units…
It reminds me of the failed Mars Climate Orbiter project. The Orbiter was launched in December 1998, spent 9 months traveling to Mars, and then burned up in the Mars atmosphere because the computer sending commands to the thrusters was sending them in pounds of force, but the spacecraft expected newtons. That was $327.6 million and years of work gone, all because of a conversion error. Thankfully no one was injured, but we lost a great opportunity to learn more about Mars.
The Tamiflu dosing error is just one of many preventable errors in medical practice. Many of these are discussed in To Err Is Human: Building a Safer Health System, published in 2000; you can read the entire report online. This has led to increased traction for practices such as printed prescriptions to counteract doctors’ sloppy handwriting and hospital protocols to avoid wrong site surgery. I won’t go into all the problems because you’d never sleep at night, but trust me that human factors professionals are in the thick of all these efforts, working to prevent errors and make medical systems and devices as foolproof as possible to keep everyone safer and healthier.
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