Providers benchmark to reduce medication errors

Automated preventative systems have best impact

An average hospital patient receives 15 or 20 medications during his or her stay. With each of those prescriptions comes an opportunity for something to go wrong. But efforts among various groups around the country are resulting in a dramatic drop in medication-related errors.

For example, the U.S. Department of Veterans Affairs recently announced that the Veterans Health Administration, the nation’s largest integrated health care system, will use computers to order and track all medications in its 173 hospitals within the next year.

Meanwhile, a new public/private coalition in Massachusetts is beginning a campaign this month to search for best practices in reducing medication errors. And the new National Patient Safety Foundation, launched last year by the American Medical Association, is working to improve patient safety.

"Error in the use of drugs is probably the most common mistake that’s made in health care," says Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health in Boston. "Studies show that health care providers make very few mistakes, but there are so many drugs used that even a very small error rate can end up being fairly significant."

Growing interest in reducing errors

Leape, who chaired two collaboratives on reducing adverse drug events for the Boston-based Institute for Healthcare Improvement, says there is increasing interest in identifying and improving processes that result in errors. "In the past, we’ve concentrated all our safety efforts on training people to be careful and punishing them when they make mistakes," Leape says. "What we’re doing now is saying we need to understand why the mistake is being made and to redesign our processes so somebody else won’t make that same mistake."

Leape points to a recent conference held by the Chicago-based National Patient Safety Foundation as evidence that many hospitals are finding effective ways to reduce errors.

Martin J. Hatlie, executive director of the foundation, says medication errors have become a hot topic. "In health care, we think things are supposed to run perfectly and that bad things happen only when some person or institution makes a mistake or is incompetent," Hatlie says. "In other high-risk industries, they acknowledge risk is everywhere. To do that, we need more and more information about where the risks in the system are. That means people have to talk about their mistakes."

Here are some of the best practices in reducing medication errors that were presented at the National Patient Safety Foundation conference in November at Rancho Mirage, CA:

o Coalition establishes best practices in reducing medication errors.

The Massachusetts Coalition for the Prevention of Medical Errors, the first statewide public-private partnership to focus solely on medical errors and system improvement, is launching a campaign this month to provide best practice recommendations for the prevention of medication errors.

The coalition — including the Massachusetts Hospital Association (MHA), the Massachusetts Medical Society, the Joint Commission on Accreditation of Healthcare Organizations, and 17 other groups — plans to establish a mechanism to identify and implement best practices for error prevention.

Using a survey tool developed by MHA and the Institute for Safe Medication Practices, baseline data will be analyzed on different approaches to safe medication administration practices. The results of the survey, along with available research on the causes of and remedies to medication errors, will be used to build consensus on the specific actions providers can take to reduce errors.

o Computerized system cuts errors by 81%.

Brigham and Women’s Hospital in Boston slashed its medication error rate by 81% through the use of a computerized physician order entry system that replaces sometimes illegibly written medication orders, according to a study by David W. Bates, MD. Non-intercepted serious medication errors — those with the potential to cause injury — fell even further, by 86%.

The system lets physicians write orders on-line, suggests appropriate doses and frequencies, and displays laboratory data and screen orders for allergies and drug interactions.

o Safety net catches dangerous drug interactions.

The pharmacy department at Barnes-Jewish Hospital and researchers at Washington University, both in St. Louis, have built a computerized "safety net" that forces a second look at 130 potentially dangerous drug interactions.

The result: The rate of potentially dangerous drug combinations for one drug, cisapride, has been cut 66%. The gastrointestinal drug previously accounted for 71% of the potentially dangerous drug interactions identified in a Barnes-Jewish Hospital study by S. Troy McMullin, PharmD, BCPS.

Using daily patient lists with detailed clinical information generated by the system, pharmacists alerted physicians, who discontinued at least one of the interacting medications in 92% of patients who were taking cisapride with another contraindicated medication. Another computerized system at Barnes-Jewish checks orders involving 41 medications for a variety of potential dosage errors, particularly those related to renal dysfunction. The number of potentially inappropriate dosages detected by the system has declined from 13.7% of drug orders screened in 1994 to 7.8% in 1997.

o Machine redesign reduces mistakes.

Programmed incorrectly, patient-controlled analgesia machines can be the instruments of a patient’s injury or death. Researchers at the University of Toronto, led by Kim J. Vicente, PhD, report that setting incorrect drug concentrations when the machines are programmed for specific patients is the most common cause of serious adverse incidents.

However, the researchers were able to reduce programming errors 55% by redesigning the machine using human factors principles such as making the functions of various controls clear and obvious. The redesign also includes providing users with prompt, useful feedback after each action, making displayed messages easy to understand, and minimizing the load on users’ memory.

o Program prevents look-alike, sound-alike errors.

When two words sound or look alike, we have a good chance of confusing them. When the names are on medications, getting them confused can cause injury or even death, says Bruce L. Lambert, PhD, a University of Illinois at Chicago researcher who has developed a computer program to catch those errors.

The program compares drug names, assesses their similarity, and then predicts the chances the name combination will be involved in a look-alike, sound-alike error. Researchers measured degrees of similarity by comparing how many two- or three-letter combinations in a pair of drug names are the same, and counting how many editing steps are needed to change one name into the other. They were able to show that the more alike two drug names are, the more likely an error would result. The researchers suggest incorporating this program into computerized physician medication order systems.

o Computer safety systems can cause their own mistakes.

A yearlong study by Roger M. Macklis, MD, of the Cleveland Clinic Foundation found that 15% of medication errors identified among cancer patients undergoing individual radiation treatments were caused by the use of an electronic check system.

The treatment machines were electronically linked via a "record and verify" computer-controlled treatment check system. Treatment could begin only when the radiation therapy machine settings agreed with a pre-programmed set of treatment prescription parameters set for that particular treatment day. Although no serious errors occurred, 59 minor errors among the study group of 1,925 patients were detected in a review of treatment transcripts and self-reported incidents by treatment technologists.

Most of the errors were minor digit transpositions that took place upon data entry into the electronic check system. In some cases, minor mistakes that probably would have been caught on handwritten data entry forms were allowed to persist because they had the authority of the computer check system format.

o Adding pharmacist to care team cuts errors.

A study at Massachusetts General Hospital in Boston found that drug information access and management was the most common system failure causing adverse drug events, so the hospital added a clinical pharmacist to a medical ICU patient care team. The results: a dramatic 77% reduction in preventable adverse drug events.

During a nine-month period in 1995-1996, the pharmacist team member intervened 398 times to clarify or correct an erroneous proposed or previous medication order, provide drug use information, recommend alternative therapy, or identify potential drug interaction and allergy problems. The hospital could save $1.9 million annually if this reduction were achieved for all ICU patients.

For more information on the Massachusetts Coalition for the Prevention of Medical Errors, contact the Massachusetts Hospital Association at (781) 272-8000.