Wrong pills, doses cause harm: Mixups leave patients at risk

[Guest guest]



http://www.app.com/article/20090405/NEWS/90405001/1001/rss

Wrong pills, doses cause harm: Mixups leave patients at risk

Mikle STAFF WRITER • April 5, 2009

Denning was dying.Dazed and dehydrated, the stocky 27-year-old was rushed to the emergency room. His organs were shutting down. He could barely breathe.

RELATED

More improvements sought at hospital Drug reactions leave patient close to death N.J. weighs computerized prescription system Hospital relying on retraining

Ancora medication report, part 3 (2 megs) Ancora medication reports, part 1 (2 megs) Ancora medication reports, part 2 (2 megs)

The cause, later noted on his medical records: Depakote toxicity and a possible reaction to Lithium. Both are powerful antipsychotic drugs used to treat Denning's paranoid schizophrenia at the state's largest psychiatric facility, Ancora Psychiatric Hospital in Winslow, Camden County.During the next few weeks, doctors struggled to keep Denning alive.In March, three months after being rushed to the hospital, a weak and disoriented Denning was a shell of his former self, his mother says."My son almost died," said his mother, Judy Denning, of Lindenwold. "My son was on life support, and this is the fault of Ancora."Denning's case is not an isolated incident.Overdoses, adverse reactions to medicines, and wrong doses of powerful drugs have harmed dozens of patients at Ancora since 2006, according to an Asbury Park Press investigation.State officials, though, say the hospital has a lengthy list of regulations and oversight aimed at reducing medication mishaps. They claim Ancora's medication error rate is far below the national average of other psychiatric hospitals.Officials also point out that patients can have adverse reactions to medications that are not always predictable and can result in serious side effects.Since December, two Ancora patients have been hospitalized because of "reactions to medications" they received inside the psychiatric hospital, according to Ellen Lovejoy, the spokeswoman for the state Department of Human Services.Brick resident Derrick , 28, who has been a patient at Ancora several times since 2002, said he could easily have been given the wrong medication because, he said, patient files were frequently in disarray."I've had my files mixed with other people's," said. "I could have been given the wrong medication. You start to feel like a guinea pig for medications in there."

Repeated mistakes

A review of hundreds of pages of Ancora medication safety and error reports by the Press found troubling patterns of mistakes and omissions at the facility, which has about 600 patients.The Press counted at least 35 cases in which patients needed additional monitoring for medication mistakes. But many of the records, obtained through the state's Open Public Records law, were blacked out. Other records were unclear, making it impossible to determine how many patients were hospitalized or needed additional monitoring because of medication errors.Problems reported from 2006 to 2008 include:— Wrong medication. Repeated instances where patients were hospitalized or needed extra supervision because they were given the wrong medicine or the wrong dose of a drug.— No medication. There were several cases where patients' medicines were omitted because they were unavailable, had not been sent by the pharmacy, or a physician had failed to order them. In one instance, a patient missed 28 doses of the anti-schizophrenic drug Clozaril because the medicine was never re-ordered.— Human error. Nurses sometimes incorrectly transcribed a doctor's orders, leading patients to miss needed doses of medicine, or to receive the wrong drugs. Nurses sometimes confused drugs with similar names, leading patients to receive the wrong medication. The pharmacy sometimes sent wrong medication or improper dosages. In May 2007,a patient was given 58 units of insulin even though the patient was not supposed to receive the drug.— Expired medicines. Patients were sometimes given drugs that were past their expiration date. Advair, an asthma medicine, was administered to a patient for 22 days after it expired.— Drugs given to wrong patients. Patients were sometimes mistakenly given another patient's medication. A nurse was disciplined after a patient received 13 doses of a drug meant for someone else. And one patient received drugs meant for another patient with the same last name.The reports from the hospital's Medication Safety Committee also noted a host of other problems, from medication stored in rooms that were too hot to narcotics kept in unlocked areas.On several occasions, drugs disappeared from the hospital, requiring police to be called. In March 2007, six Tylenol 3 with Codeine were missing from Cedar Hall, resulting in a nurse being disciplined. The report did not detail the type of discipline.Brick resident Gerald , a patient at Ancora from June to August 2007, said it was common for illegal drugs to be smuggled into the hospital."I saw a guy in the visitor's room putting pills down a girl's shirt," said. On other occasions, hospital staff would "turn everybody's room upside down, looking for pills," he said. Painkillers were the favorite drugs to be stolen or smuggled in, said.

Psych hospital errors more dangerous

State officials defend Ancora's record, saying the hospital's medication error rate is far below the national average.Lovejoy, the spokeswoman for Human Services, said Ancora's medication error rate was 2.4 percent in 2008; 3 percent in 2007 and 2.2 percent in 2006."I don't think there is any disputing by any yardstick that we are well below the national average," Lovejoy said. The state receives information on U.S. averages from the National Association of State Mental Health Program Directors, which measures the number of errors for each 100 episodes of patient care, she said.Nationally, there are errors made in about three to five of every 100 doses of medicine, according to R. Cohen, president of Institute for Safe Medication Practices, a nonprofit organization dedicated to medication error prevention and safe medication use.Cohen said that figure includes all hospitals; he was unaware of any national studies that focused solely on psychiatric hospitals.A 2007 study, Medication Safety in a Psychiatric Hospital, which appeared in the March/April 2007 edition of General Hospital Psychiatry, found that the rate of serious medication errors at one hospital was 6.3 per 1,000 patient days, with an adverse drug reaction rate of 10 per 1,000 patient days.A patient day is the number of days a person is hospitalized. If 10 people are in the hospital for 10 days, that would be a total of 100 patient days.Adverse drug reactions are side effects from certain medications that often can not be predicted. They are more frequent in patients taking multiple medications.A 2006 study by the Institute of Medicine said medication errors harm at least 1.5 million people a year, with the extra cost of treating medication-related injuries pegged at $3.5 billion.Cohen said that errors made in a psychiatric hospital could be more dangerous than those made in a traditional hospital setting, because a minor change in the dosage or the time when a powerful antipsychotic drug is administered can have severe effects on a patient."Most of the drugs (administered in hospitals), it does not matter if you give a tablet at 10 o'clock or 2 o'clock," Cohen said. "In that setting, it's more important to have the drugs given at a very specific time or there can be problems."He pointed out that hospitals sometimes minimize errors, saying they cause no harm to patients if the mistake does not lead to a serious illness or adverse reaction.At Ancora, for example, a patient missed 58 doses of Anbesol, used for mouth pain, because the medicine was not available. This error was considered by Ancora officials to have caused no harm to the patient under the hospital's reporting standards.

Under-reported errors

Most errors in Ancora are self-reported, as they are in almost all hospitals. Experts say that means many errors are likely not reported.A 2002 study by Grasso, Genest, Constance Jordan and W. Bates reviewed medical charts and medication error rates for 31 patients hospitalized for two months in a state psychiatric facility. Their conclusion: staffers greatly under-reported drug mistakes, including potentially deadly errors.Hospital staff reported 9 errors per 1,448 patient days.But the study actually found a total of 2,194 errors, of which 58 percent had the potential to cause severe harm to patients. The study did not identify the hospital."Error rates are generally calculated by taking the number of self-reported errors from nursing staff and expressing it as a percentage of all medications dispensed," Bates and Grasso wrote in a 2003 article published in "Psychiatric Services.""Such rates are usually substantially lower than actual rates because of the flaws inherent in self-reporting."Errors occur more often when hospitals are understaffed or overcrowded, studies have shown.Ancora, severely overcrowded in recent years, reduced its patient population in 2008 following reports by the Press of violence inside the facility.Distractions were an issue in a July 2006 error, according to Medication Safety Committee records.A patient in Ancora's Main Building received doses of a medication that was not ordered, after drugs for another patient were mistakenly transcribed onto the wrong person's chart.The reason, according to documents: "Nurse stated too many distractions caused error."

WEB EXTRA

Quickly review three years of Medication Safety Committee reports from Ancora Psychiatric Hospital by using our “Phrase Tree†and “Word Tree†interactive graphics. These will show you the most used words in the reports to help you quickly explore hundreds of pages of information.

[Guest guest]



http://www.app.com/article/20090405/NEWS/90405001/1001/rss

Wrong pills, doses cause harm: Mixups leave patients at risk

Mikle STAFF WRITER • April 5, 2009

Denning was dying.Dazed and dehydrated, the stocky 27-year-old was rushed to the emergency room. His organs were shutting down. He could barely breathe.

RELATED

More improvements sought at hospital Drug reactions leave patient close to death N.J. weighs computerized prescription system Hospital relying on retraining

Ancora medication report, part 3 (2 megs) Ancora medication reports, part 1 (2 megs) Ancora medication reports, part 2 (2 megs)

The cause, later noted on his medical records: Depakote toxicity and a possible reaction to Lithium. Both are powerful antipsychotic drugs used to treat Denning's paranoid schizophrenia at the state's largest psychiatric facility, Ancora Psychiatric Hospital in Winslow, Camden County.During the next few weeks, doctors struggled to keep Denning alive.In March, three months after being rushed to the hospital, a weak and disoriented Denning was a shell of his former self, his mother says."My son almost died," said his mother, Judy Denning, of Lindenwold. "My son was on life support, and this is the fault of Ancora."Denning's case is not an isolated incident.Overdoses, adverse reactions to medicines, and wrong doses of powerful drugs have harmed dozens of patients at Ancora since 2006, according to an Asbury Park Press investigation.State officials, though, say the hospital has a lengthy list of regulations and oversight aimed at reducing medication mishaps. They claim Ancora's medication error rate is far below the national average of other psychiatric hospitals.Officials also point out that patients can have adverse reactions to medications that are not always predictable and can result in serious side effects.Since December, two Ancora patients have been hospitalized because of "reactions to medications" they received inside the psychiatric hospital, according to Ellen Lovejoy, the spokeswoman for the state Department of Human Services.Brick resident Derrick , 28, who has been a patient at Ancora several times since 2002, said he could easily have been given the wrong medication because, he said, patient files were frequently in disarray."I've had my files mixed with other people's," said. "I could have been given the wrong medication. You start to feel like a guinea pig for medications in there."

Repeated mistakes

A review of hundreds of pages of Ancora medication safety and error reports by the Press found troubling patterns of mistakes and omissions at the facility, which has about 600 patients.The Press counted at least 35 cases in which patients needed additional monitoring for medication mistakes. But many of the records, obtained through the state's Open Public Records law, were blacked out. Other records were unclear, making it impossible to determine how many patients were hospitalized or needed additional monitoring because of medication errors.Problems reported from 2006 to 2008 include:— Wrong medication. Repeated instances where patients were hospitalized or needed extra supervision because they were given the wrong medicine or the wrong dose of a drug.— No medication. There were several cases where patients' medicines were omitted because they were unavailable, had not been sent by the pharmacy, or a physician had failed to order them. In one instance, a patient missed 28 doses of the anti-schizophrenic drug Clozaril because the medicine was never re-ordered.— Human error. Nurses sometimes incorrectly transcribed a doctor's orders, leading patients to miss needed doses of medicine, or to receive the wrong drugs. Nurses sometimes confused drugs with similar names, leading patients to receive the wrong medication. The pharmacy sometimes sent wrong medication or improper dosages. In May 2007,a patient was given 58 units of insulin even though the patient was not supposed to receive the drug.— Expired medicines. Patients were sometimes given drugs that were past their expiration date. Advair, an asthma medicine, was administered to a patient for 22 days after it expired.— Drugs given to wrong patients. Patients were sometimes mistakenly given another patient's medication. A nurse was disciplined after a patient received 13 doses of a drug meant for someone else. And one patient received drugs meant for another patient with the same last name.The reports from the hospital's Medication Safety Committee also noted a host of other problems, from medication stored in rooms that were too hot to narcotics kept in unlocked areas.On several occasions, drugs disappeared from the hospital, requiring police to be called. In March 2007, six Tylenol 3 with Codeine were missing from Cedar Hall, resulting in a nurse being disciplined. The report did not detail the type of discipline.Brick resident Gerald , a patient at Ancora from June to August 2007, said it was common for illegal drugs to be smuggled into the hospital."I saw a guy in the visitor's room putting pills down a girl's shirt," said. On other occasions, hospital staff would "turn everybody's room upside down, looking for pills," he said. Painkillers were the favorite drugs to be stolen or smuggled in, said.

Psych hospital errors more dangerous

State officials defend Ancora's record, saying the hospital's medication error rate is far below the national average.Lovejoy, the spokeswoman for Human Services, said Ancora's medication error rate was 2.4 percent in 2008; 3 percent in 2007 and 2.2 percent in 2006."I don't think there is any disputing by any yardstick that we are well below the national average," Lovejoy said. The state receives information on U.S. averages from the National Association of State Mental Health Program Directors, which measures the number of errors for each 100 episodes of patient care, she said.Nationally, there are errors made in about three to five of every 100 doses of medicine, according to R. Cohen, president of Institute for Safe Medication Practices, a nonprofit organization dedicated to medication error prevention and safe medication use.Cohen said that figure includes all hospitals; he was unaware of any national studies that focused solely on psychiatric hospitals.A 2007 study, Medication Safety in a Psychiatric Hospital, which appeared in the March/April 2007 edition of General Hospital Psychiatry, found that the rate of serious medication errors at one hospital was 6.3 per 1,000 patient days, with an adverse drug reaction rate of 10 per 1,000 patient days.A patient day is the number of days a person is hospitalized. If 10 people are in the hospital for 10 days, that would be a total of 100 patient days.Adverse drug reactions are side effects from certain medications that often can not be predicted. They are more frequent in patients taking multiple medications.A 2006 study by the Institute of Medicine said medication errors harm at least 1.5 million people a year, with the extra cost of treating medication-related injuries pegged at $3.5 billion.Cohen said that errors made in a psychiatric hospital could be more dangerous than those made in a traditional hospital setting, because a minor change in the dosage or the time when a powerful antipsychotic drug is administered can have severe effects on a patient."Most of the drugs (administered in hospitals), it does not matter if you give a tablet at 10 o'clock or 2 o'clock," Cohen said. "In that setting, it's more important to have the drugs given at a very specific time or there can be problems."He pointed out that hospitals sometimes minimize errors, saying they cause no harm to patients if the mistake does not lead to a serious illness or adverse reaction.At Ancora, for example, a patient missed 58 doses of Anbesol, used for mouth pain, because the medicine was not available. This error was considered by Ancora officials to have caused no harm to the patient under the hospital's reporting standards.

Under-reported errors

Most errors in Ancora are self-reported, as they are in almost all hospitals. Experts say that means many errors are likely not reported.A 2002 study by Grasso, Genest, Constance Jordan and W. Bates reviewed medical charts and medication error rates for 31 patients hospitalized for two months in a state psychiatric facility. Their conclusion: staffers greatly under-reported drug mistakes, including potentially deadly errors.Hospital staff reported 9 errors per 1,448 patient days.But the study actually found a total of 2,194 errors, of which 58 percent had the potential to cause severe harm to patients. The study did not identify the hospital."Error rates are generally calculated by taking the number of self-reported errors from nursing staff and expressing it as a percentage of all medications dispensed," Bates and Grasso wrote in a 2003 article published in "Psychiatric Services.""Such rates are usually substantially lower than actual rates because of the flaws inherent in self-reporting."Errors occur more often when hospitals are understaffed or overcrowded, studies have shown.Ancora, severely overcrowded in recent years, reduced its patient population in 2008 following reports by the Press of violence inside the facility.Distractions were an issue in a July 2006 error, according to Medication Safety Committee records.A patient in Ancora's Main Building received doses of a medication that was not ordered, after drugs for another patient were mistakenly transcribed onto the wrong person's chart.The reason, according to documents: "Nurse stated too many distractions caused error."

WEB EXTRA

Quickly review three years of Medication Safety Committee reports from Ancora Psychiatric Hospital by using our “Phrase Tree†and “Word Tree†interactive graphics. These will show you the most used words in the reports to help you quickly explore hundreds of pages of information.

[Guest guest]



http://www.app.com/article/20090405/NEWS/90405001/1001/rss

Wrong pills, doses cause harm: Mixups leave patients at risk

Mikle STAFF WRITER • April 5, 2009

Denning was dying.Dazed and dehydrated, the stocky 27-year-old was rushed to the emergency room. His organs were shutting down. He could barely breathe.

RELATED

More improvements sought at hospital Drug reactions leave patient close to death N.J. weighs computerized prescription system Hospital relying on retraining

Ancora medication report, part 3 (2 megs) Ancora medication reports, part 1 (2 megs) Ancora medication reports, part 2 (2 megs)

The cause, later noted on his medical records: Depakote toxicity and a possible reaction to Lithium. Both are powerful antipsychotic drugs used to treat Denning's paranoid schizophrenia at the state's largest psychiatric facility, Ancora Psychiatric Hospital in Winslow, Camden County.During the next few weeks, doctors struggled to keep Denning alive.In March, three months after being rushed to the hospital, a weak and disoriented Denning was a shell of his former self, his mother says."My son almost died," said his mother, Judy Denning, of Lindenwold. "My son was on life support, and this is the fault of Ancora."Denning's case is not an isolated incident.Overdoses, adverse reactions to medicines, and wrong doses of powerful drugs have harmed dozens of patients at Ancora since 2006, according to an Asbury Park Press investigation.State officials, though, say the hospital has a lengthy list of regulations and oversight aimed at reducing medication mishaps. They claim Ancora's medication error rate is far below the national average of other psychiatric hospitals.Officials also point out that patients can have adverse reactions to medications that are not always predictable and can result in serious side effects.Since December, two Ancora patients have been hospitalized because of "reactions to medications" they received inside the psychiatric hospital, according to Ellen Lovejoy, the spokeswoman for the state Department of Human Services.Brick resident Derrick , 28, who has been a patient at Ancora several times since 2002, said he could easily have been given the wrong medication because, he said, patient files were frequently in disarray."I've had my files mixed with other people's," said. "I could have been given the wrong medication. You start to feel like a guinea pig for medications in there."

Repeated mistakes

A review of hundreds of pages of Ancora medication safety and error reports by the Press found troubling patterns of mistakes and omissions at the facility, which has about 600 patients.The Press counted at least 35 cases in which patients needed additional monitoring for medication mistakes. But many of the records, obtained through the state's Open Public Records law, were blacked out. Other records were unclear, making it impossible to determine how many patients were hospitalized or needed additional monitoring because of medication errors.Problems reported from 2006 to 2008 include:— Wrong medication. Repeated instances where patients were hospitalized or needed extra supervision because they were given the wrong medicine or the wrong dose of a drug.— No medication. There were several cases where patients' medicines were omitted because they were unavailable, had not been sent by the pharmacy, or a physician had failed to order them. In one instance, a patient missed 28 doses of the anti-schizophrenic drug Clozaril because the medicine was never re-ordered.— Human error. Nurses sometimes incorrectly transcribed a doctor's orders, leading patients to miss needed doses of medicine, or to receive the wrong drugs. Nurses sometimes confused drugs with similar names, leading patients to receive the wrong medication. The pharmacy sometimes sent wrong medication or improper dosages. In May 2007,a patient was given 58 units of insulin even though the patient was not supposed to receive the drug.— Expired medicines. Patients were sometimes given drugs that were past their expiration date. Advair, an asthma medicine, was administered to a patient for 22 days after it expired.— Drugs given to wrong patients. Patients were sometimes mistakenly given another patient's medication. A nurse was disciplined after a patient received 13 doses of a drug meant for someone else. And one patient received drugs meant for another patient with the same last name.The reports from the hospital's Medication Safety Committee also noted a host of other problems, from medication stored in rooms that were too hot to narcotics kept in unlocked areas.On several occasions, drugs disappeared from the hospital, requiring police to be called. In March 2007, six Tylenol 3 with Codeine were missing from Cedar Hall, resulting in a nurse being disciplined. The report did not detail the type of discipline.Brick resident Gerald , a patient at Ancora from June to August 2007, said it was common for illegal drugs to be smuggled into the hospital."I saw a guy in the visitor's room putting pills down a girl's shirt," said. On other occasions, hospital staff would "turn everybody's room upside down, looking for pills," he said. Painkillers were the favorite drugs to be stolen or smuggled in, said.

Psych hospital errors more dangerous

State officials defend Ancora's record, saying the hospital's medication error rate is far below the national average.Lovejoy, the spokeswoman for Human Services, said Ancora's medication error rate was 2.4 percent in 2008; 3 percent in 2007 and 2.2 percent in 2006."I don't think there is any disputing by any yardstick that we are well below the national average," Lovejoy said. The state receives information on U.S. averages from the National Association of State Mental Health Program Directors, which measures the number of errors for each 100 episodes of patient care, she said.Nationally, there are errors made in about three to five of every 100 doses of medicine, according to R. Cohen, president of Institute for Safe Medication Practices, a nonprofit organization dedicated to medication error prevention and safe medication use.Cohen said that figure includes all hospitals; he was unaware of any national studies that focused solely on psychiatric hospitals.A 2007 study, Medication Safety in a Psychiatric Hospital, which appeared in the March/April 2007 edition of General Hospital Psychiatry, found that the rate of serious medication errors at one hospital was 6.3 per 1,000 patient days, with an adverse drug reaction rate of 10 per 1,000 patient days.A patient day is the number of days a person is hospitalized. If 10 people are in the hospital for 10 days, that would be a total of 100 patient days.Adverse drug reactions are side effects from certain medications that often can not be predicted. They are more frequent in patients taking multiple medications.A 2006 study by the Institute of Medicine said medication errors harm at least 1.5 million people a year, with the extra cost of treating medication-related injuries pegged at $3.5 billion.Cohen said that errors made in a psychiatric hospital could be more dangerous than those made in a traditional hospital setting, because a minor change in the dosage or the time when a powerful antipsychotic drug is administered can have severe effects on a patient."Most of the drugs (administered in hospitals), it does not matter if you give a tablet at 10 o'clock or 2 o'clock," Cohen said. "In that setting, it's more important to have the drugs given at a very specific time or there can be problems."He pointed out that hospitals sometimes minimize errors, saying they cause no harm to patients if the mistake does not lead to a serious illness or adverse reaction.At Ancora, for example, a patient missed 58 doses of Anbesol, used for mouth pain, because the medicine was not available. This error was considered by Ancora officials to have caused no harm to the patient under the hospital's reporting standards.

Under-reported errors

Most errors in Ancora are self-reported, as they are in almost all hospitals. Experts say that means many errors are likely not reported.A 2002 study by Grasso, Genest, Constance Jordan and W. Bates reviewed medical charts and medication error rates for 31 patients hospitalized for two months in a state psychiatric facility. Their conclusion: staffers greatly under-reported drug mistakes, including potentially deadly errors.Hospital staff reported 9 errors per 1,448 patient days.But the study actually found a total of 2,194 errors, of which 58 percent had the potential to cause severe harm to patients. The study did not identify the hospital."Error rates are generally calculated by taking the number of self-reported errors from nursing staff and expressing it as a percentage of all medications dispensed," Bates and Grasso wrote in a 2003 article published in "Psychiatric Services.""Such rates are usually substantially lower than actual rates because of the flaws inherent in self-reporting."Errors occur more often when hospitals are understaffed or overcrowded, studies have shown.Ancora, severely overcrowded in recent years, reduced its patient population in 2008 following reports by the Press of violence inside the facility.Distractions were an issue in a July 2006 error, according to Medication Safety Committee records.A patient in Ancora's Main Building received doses of a medication that was not ordered, after drugs for another patient were mistakenly transcribed onto the wrong person's chart.The reason, according to documents: "Nurse stated too many distractions caused error."

WEB EXTRA

Quickly review three years of Medication Safety Committee reports from Ancora Psychiatric Hospital by using our “Phrase Tree†and “Word Tree†interactive graphics. These will show you the most used words in the reports to help you quickly explore hundreds of pages of information.

[Guest guest]



http://www.app.com/article/20090405/NEWS/90405001/1001/rss

Wrong pills, doses cause harm: Mixups leave patients at risk

Mikle STAFF WRITER • April 5, 2009

Denning was dying.Dazed and dehydrated, the stocky 27-year-old was rushed to the emergency room. His organs were shutting down. He could barely breathe.

RELATED

More improvements sought at hospital Drug reactions leave patient close to death N.J. weighs computerized prescription system Hospital relying on retraining

Ancora medication report, part 3 (2 megs) Ancora medication reports, part 1 (2 megs) Ancora medication reports, part 2 (2 megs)

The cause, later noted on his medical records: Depakote toxicity and a possible reaction to Lithium. Both are powerful antipsychotic drugs used to treat Denning's paranoid schizophrenia at the state's largest psychiatric facility, Ancora Psychiatric Hospital in Winslow, Camden County.During the next few weeks, doctors struggled to keep Denning alive.In March, three months after being rushed to the hospital, a weak and disoriented Denning was a shell of his former self, his mother says."My son almost died," said his mother, Judy Denning, of Lindenwold. "My son was on life support, and this is the fault of Ancora."Denning's case is not an isolated incident.Overdoses, adverse reactions to medicines, and wrong doses of powerful drugs have harmed dozens of patients at Ancora since 2006, according to an Asbury Park Press investigation.State officials, though, say the hospital has a lengthy list of regulations and oversight aimed at reducing medication mishaps. They claim Ancora's medication error rate is far below the national average of other psychiatric hospitals.Officials also point out that patients can have adverse reactions to medications that are not always predictable and can result in serious side effects.Since December, two Ancora patients have been hospitalized because of "reactions to medications" they received inside the psychiatric hospital, according to Ellen Lovejoy, the spokeswoman for the state Department of Human Services.Brick resident Derrick , 28, who has been a patient at Ancora several times since 2002, said he could easily have been given the wrong medication because, he said, patient files were frequently in disarray."I've had my files mixed with other people's," said. "I could have been given the wrong medication. You start to feel like a guinea pig for medications in there."

Repeated mistakes

A review of hundreds of pages of Ancora medication safety and error reports by the Press found troubling patterns of mistakes and omissions at the facility, which has about 600 patients.The Press counted at least 35 cases in which patients needed additional monitoring for medication mistakes. But many of the records, obtained through the state's Open Public Records law, were blacked out. Other records were unclear, making it impossible to determine how many patients were hospitalized or needed additional monitoring because of medication errors.Problems reported from 2006 to 2008 include:— Wrong medication. Repeated instances where patients were hospitalized or needed extra supervision because they were given the wrong medicine or the wrong dose of a drug.— No medication. There were several cases where patients' medicines were omitted because they were unavailable, had not been sent by the pharmacy, or a physician had failed to order them. In one instance, a patient missed 28 doses of the anti-schizophrenic drug Clozaril because the medicine was never re-ordered.— Human error. Nurses sometimes incorrectly transcribed a doctor's orders, leading patients to miss needed doses of medicine, or to receive the wrong drugs. Nurses sometimes confused drugs with similar names, leading patients to receive the wrong medication. The pharmacy sometimes sent wrong medication or improper dosages. In May 2007,a patient was given 58 units of insulin even though the patient was not supposed to receive the drug.— Expired medicines. Patients were sometimes given drugs that were past their expiration date. Advair, an asthma medicine, was administered to a patient for 22 days after it expired.— Drugs given to wrong patients. Patients were sometimes mistakenly given another patient's medication. A nurse was disciplined after a patient received 13 doses of a drug meant for someone else. And one patient received drugs meant for another patient with the same last name.The reports from the hospital's Medication Safety Committee also noted a host of other problems, from medication stored in rooms that were too hot to narcotics kept in unlocked areas.On several occasions, drugs disappeared from the hospital, requiring police to be called. In March 2007, six Tylenol 3 with Codeine were missing from Cedar Hall, resulting in a nurse being disciplined. The report did not detail the type of discipline.Brick resident Gerald , a patient at Ancora from June to August 2007, said it was common for illegal drugs to be smuggled into the hospital."I saw a guy in the visitor's room putting pills down a girl's shirt," said. On other occasions, hospital staff would "turn everybody's room upside down, looking for pills," he said. Painkillers were the favorite drugs to be stolen or smuggled in, said.

Psych hospital errors more dangerous

State officials defend Ancora's record, saying the hospital's medication error rate is far below the national average.Lovejoy, the spokeswoman for Human Services, said Ancora's medication error rate was 2.4 percent in 2008; 3 percent in 2007 and 2.2 percent in 2006."I don't think there is any disputing by any yardstick that we are well below the national average," Lovejoy said. The state receives information on U.S. averages from the National Association of State Mental Health Program Directors, which measures the number of errors for each 100 episodes of patient care, she said.Nationally, there are errors made in about three to five of every 100 doses of medicine, according to R. Cohen, president of Institute for Safe Medication Practices, a nonprofit organization dedicated to medication error prevention and safe medication use.Cohen said that figure includes all hospitals; he was unaware of any national studies that focused solely on psychiatric hospitals.A 2007 study, Medication Safety in a Psychiatric Hospital, which appeared in the March/April 2007 edition of General Hospital Psychiatry, found that the rate of serious medication errors at one hospital was 6.3 per 1,000 patient days, with an adverse drug reaction rate of 10 per 1,000 patient days.A patient day is the number of days a person is hospitalized. If 10 people are in the hospital for 10 days, that would be a total of 100 patient days.Adverse drug reactions are side effects from certain medications that often can not be predicted. They are more frequent in patients taking multiple medications.A 2006 study by the Institute of Medicine said medication errors harm at least 1.5 million people a year, with the extra cost of treating medication-related injuries pegged at $3.5 billion.Cohen said that errors made in a psychiatric hospital could be more dangerous than those made in a traditional hospital setting, because a minor change in the dosage or the time when a powerful antipsychotic drug is administered can have severe effects on a patient."Most of the drugs (administered in hospitals), it does not matter if you give a tablet at 10 o'clock or 2 o'clock," Cohen said. "In that setting, it's more important to have the drugs given at a very specific time or there can be problems."He pointed out that hospitals sometimes minimize errors, saying they cause no harm to patients if the mistake does not lead to a serious illness or adverse reaction.At Ancora, for example, a patient missed 58 doses of Anbesol, used for mouth pain, because the medicine was not available. This error was considered by Ancora officials to have caused no harm to the patient under the hospital's reporting standards.

Under-reported errors

Most errors in Ancora are self-reported, as they are in almost all hospitals. Experts say that means many errors are likely not reported.A 2002 study by Grasso, Genest, Constance Jordan and W. Bates reviewed medical charts and medication error rates for 31 patients hospitalized for two months in a state psychiatric facility. Their conclusion: staffers greatly under-reported drug mistakes, including potentially deadly errors.Hospital staff reported 9 errors per 1,448 patient days.But the study actually found a total of 2,194 errors, of which 58 percent had the potential to cause severe harm to patients. The study did not identify the hospital."Error rates are generally calculated by taking the number of self-reported errors from nursing staff and expressing it as a percentage of all medications dispensed," Bates and Grasso wrote in a 2003 article published in "Psychiatric Services.""Such rates are usually substantially lower than actual rates because of the flaws inherent in self-reporting."Errors occur more often when hospitals are understaffed or overcrowded, studies have shown.Ancora, severely overcrowded in recent years, reduced its patient population in 2008 following reports by the Press of violence inside the facility.Distractions were an issue in a July 2006 error, according to Medication Safety Committee records.A patient in Ancora's Main Building received doses of a medication that was not ordered, after drugs for another patient were mistakenly transcribed onto the wrong person's chart.The reason, according to documents: "Nurse stated too many distractions caused error."

WEB EXTRA

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