What Is It About The Number "Ten" and Dosage Errors?

1 Ok was reading a news story from New Zealand hospital coping with several med dosage errors by nurses, with a few of them causing the ultimate poor outcome - death. What struck me is that as with reported errors here in the United States making the news recently the dosage was calcuated incorrectly by the nurses so ten times the correct amount was given. Why is it always "ten" and is there some sort of worldwide problem working with decimal points?
I believe we're talking about mg per ml ratios. With my experience it's been done with the multi-dose liquid draw bottles of morphine that come in multiple doses ranging anywhere from 10mg per ml to 50mg per ml and on up. You grab the wrong bottle and don't check ... well there ya go.

My work has electronic MARs so I'm always worried the pharmacy will have a hard time reading my orders and not put the decimal in the right place. I've heard some horror stories from my DOC who has transcribed orders only to find the MD wrote them with the decimal in the wrong place making the dose 10 times the required amount. What a scary thought.

The metric system operates on the power of ten, and when calculating dosages based on mg/mL it's very easy to misplace a decimal (provider, secretary, pharmacy, nurse- that's at least 4 people that have to get it exactly right every time)

Quote from AngelicDarknessMy work has electronic MARs so I'm always worried the pharmacy will have a hard time reading my orders and not put the decimal in the right place. I've heard some horror stories from my DOC who has transcribed orders only to find the MD wrote them with the decimal in the wrong place making the dose 10 times the required amount. What a scary thought.

Ultimately at the very end of the day I will pin this on hospitals not staffing properly. it is time for legislation to mandate staffing levels.

Whenever I'm about to write out digits, I always slow down and make sure each digit is clear, that there is enough spacing around each digit, and that the decimal point is big enough to be obvious. You can afford to have a little sloppier handwriting when writing many words that can be figured out from context (well, except for certain med names), but I think it's always worth the time to slow down for the dosage digits, and units for that matter.

Quote from tvccrnThis simply outlines the importance of the nurses knowing the correct dosage for the medications they are giving. Whether it is the amount or the form (mg vs. mcg), if you know what the normal dose is then you can clarify an order that is incorrectly written.

med dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

Quote from Chemistry Suxmed dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

Quote from DoGoodThenGoOk was reading a news story from New Zealand hospital coping with several med dosage errors by nurses, with a few of them causing the ultimate poor outcome - death. What struck me is that as with reported errors here in the United States making the news recently the dosage was calcuated incorrectly by the nurses so ten times the correct amount was given. Why is it always "ten" and is there some sort of worldwide problem working with decimal points?

Quote from Chemistry Suxmed dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

Quote from tvccrnThis simply outlines the importance of the nurses knowing the correct dosage for the medications they are giving. Whether it is the amount or the form (mg vs. mcg), if you know what the normal dose is then you can clarify an order that is incorrectly written.