The mystery of how three babies in the critical care nursery at Anne Arundel Medical Center were poisoned by morphine has been solved. Investigators concluded last week that a pharmacist at the Annapolis hospital made a mistake in mixing drugs that were given to the infants.
While we're glad the truth has been discovered, we can't be altogether relieved.
The incident is disturbing not because a mistake was made at arespected hospital, but because such a mistake could have happened anywhere.
State licensing officials found that in general Anne Arundel Medical Center is a good and safe hospital. Still, investigators uncovered numerous lapses in safety procedures.
Nurses had made mistakes in records and pharmacists had not documented all medicines given to the babies. The pharmacy was not adequately secured. The morphine was stored in a way that could have led to confusion with other drugs. Most troubling of all, the pharmacist who made the mistake had not renewed her license after it expired.
Carol Benner, director of the state's Office of Licensing and Certification programs, said the licensing lapse was an isolated incident. "It fits in the category of 'stuff happens,' " she said.
But according to consumer health advocates, drug-related lapses are all too common. Pharmacists have trouble reading doctor's handwriting, similarly packaged drugs may be mixed up, dosage directions may be unclear. Some experts estimate one hospitalized American dies every day as the result of medication errors.
Fortunately, none of the infants at Anne Arundel Medical Center died, but the incident should send a wake-up call to the medical center and all state hospitals that greater vigilance is needed to assure that medicines are dispensed safely.
Hospitals ought to make certain that their drugs are properly labeled and stored and consider requiring a second pharmacist to double-check prescriptions when they are filled.
Hospitals the size of Anne Arundel Medical Center dispense about 5 million doses of medicine to patients each year. Errors are rare. But when they occur, they can be deadly. Patients have a right to expect every possible precaution is being taken to avoid mistakes.