After subsequent hospitalisation, Chhabra’s troubles due to the wrong drug were over, but his case is not an isolated example of erroneous drug administration in city hospitals. From writing a medical prescription to administering medicines to patients on hospital beds, there are many areas where an error can be committed.

The Delhi Government seems to be gradually waking up to this danger.

In a novel initiative, the Directorate of Health Services (DHS) has launched training modules in rational use of drugs for doctors and pharmacists. The training also focuses on nurses, thereby making drug administration a team effort from the time it is prescribed to the moment it reaches the patient.

Last month, nearly 40 nurses from government-run hospitals in Delhi were trained by the DHS in identifying the right drugs, the right dose and the right duration of a particular drug for a patient. The major participant hospitals were DDU Hospital, LNJP Hospital, GB Pant Hospital and MAMC Hospital.

“Most of the errors occur while dealing with look-alike health products or those which sound similar. These similarities may pose a risk to health by contributing to medical errors in prescribing, documenting, dispensing or administering a product,” says Dr Usha Gupta, former head of Pharmacology department at the Maulana Azad Medical College who conducted the training.

Gupta points out that medication errors may occur more because of contributing factors such as identical doses, dosage forms or routes of administration, similar packaging or labelling, incomplete knowledge of drug names, illegible handwriting, verbal order errors and even lack of an appropriate knowledge base.

It is estimated that confusion regarding drug names is thought to account for 25 per cent of all medication errors. But what is more troubling is that most of the time, the nurses may not even be aware of the errors they made, says Dr Gupta. “Be it a private or a government hospital, errors do occur. My experience says nurses often do not even realise that they committed an error. Right drug administration is also not being dealt with an in-depth manner while training nurses,” she adds.

But what augments the problem is the absence of an error-reporting mechanism in city hospitals that could keep an account of errors through an internal audit. “Our idea is therefore to educate them not to be afraid of reporting the errors. Every hospital should have a blame free system that recognises human error as an inevitable consequence and systems are put in place to minimise consequences,” says Dr Gupta, who is also executive vice-president of the Society for Rational Use of Drugs, a policy intervention group that is collaborating with DHS for the training programmes.

But since there is no system in place, there is hardly any data on medication errors in city hospitals. In the US, medication errors account for 7,000 deaths annually.