Friday, December 28, 2007

Adverse drug reactions

Allergy to medicines 'is killing thousands' - Article in the Time Online on 27 December 2007 by David Rose.

Nearly 3,000 patients have died in the past three years as a result of taking medicines intended to help them, official figures show. Thousands more have been hospitalised after suffering harmful side-effects or serious allergic reactions to prescription drugs and other medications.

Drugs most commonly implicated in adverse reactions include low-dose aspirin, diuretics, the anticoagulant drug warfarin and other nonsteroidal antiinflammatory drugs. The most common problem associated with these medications is gastrointestinal bleeding, which can be fatal. But many of the reactions were likely to be because of incorrect dosages or known interactions of the drugs and as such were avoidable, research suggests.

Teresa Innes, 38, lapsed into a coma in September 2001 after a surgeon at Bradford Royal Infirmary prescribed a drug containing penicillin as she was about to undergo a routine procedure to drain fluid from an abscess on her thigh. Despite wearing a red allergy band on her wrist and medical notes giving warning about her acute aversion to the antibiotic, Mrs Innes was given the drug Magnapen, which staff did not realise contained penicillin.

The former care worker suffered an-aphylactic shock, which stopped her heart for 35 minutes, resulting in permanent brain damage. She was left in a persistent vegetative state from which she never recovered. She died two years later.

This is a good example of how complex it is for someone to become competent in a task. In this case it seems likely that everyone knew about Teresa's allergy, but did not have deep enough knowledge of the drug. Given the number of drugs used in health care this is hardly surprising. Some form of job aid could probably help, if people would use it in practice.

Andy Brazier

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