Medical errors top list of public’s concerns

Arizona agency has QI project that reduces them

Health care organizations received an ego blow at the end of 1999 when an Institute of Medicine (IOM) report claimed that between 44,000 and 98,000 Americans die each year from medical errors.

These errors occur in all areas of health care and also result in permanent disabilities, according to William Richardson, chairman of the IOM committee that wrote the report.

The report followed quickly on the heels of an October 1999 jury decision in which a Texas man’s family was awarded $450,000 after the man died when given a drug to treat high blood pressure. He had been prescribed a drug for chest pain, and the pharmacist misread the cardiologist’s handwriting. Both the Albertson’s pharmacy in Odessa, TX, and the cardiologist, Ramachandra Kolluru, MD, were sued, and the verdict required them each to pay half the damages.

Other reports suggest that drug errors are on the rise. One study showed that medication errors nearly tripled from 1983 to 1993, and deaths from medication errors increased from about 3,000 in 1983 to more than 7,000 in 1993. The same study suggests that shorter hospital stays and a shift toward outpatient care have led to those medication problems.

Due to those alarming reports, President Clinton announced last December a list of initiatives to reduce medical errors and improve medication safety.

Home care staff are in a position to prevent some of those mistakes because they have access to patient’s medicine cabinets and can find out more about what the patient is taking than what any one physician might know.

"We find an accumulation of medications, and lots of times the doctor doesn’t even know what they’re taking," says Loretta Wellborn, RN, MS, director of Northern Arizona Homecare in Flagstaff, AZ.

Northern Arizona Homecare has taken a series of quality improvement steps to prevent medication and other medical errors. These include:

Create medication profile. Nurses, using laptop computers for documentation, create a medication profile of each home care patient. They list all of the patient’s prescribed and over-the-counter drugs, based on what patients say they are taking and what nurses observe during a home care visit.

Once those profiles are logged in, the software program creates medication teaching sheets that nurses can review with patients. The program also alerts nurses to any potential food-drug or drug-drug interactions.

Have pharmacist review med profile. The agency has its own staff pharmacist who reviews the medication profiles to make sure there are not any potential problems. For example, if a patient is prescribed the drug Coumadin and the patient also takes aspirin, there could be a significant drug interaction, Wellborn explains. "We end up being a detective in home health."

Nurses will also consult with the pharmacist when the patient experiences problems that could be side effects from one or more medications. The pharmacist is often in the best position to determine whether a drug is causing a side effect, Wellborn says. "It could be from a drug the patient was prescribed earlier; and since everyone has different doctors these days, with one specialist for one medication and another specialist for another medication, we try to monitor that closely."

Investigate all adverse reactions. Whenever patients have an adverse drug reaction, the home care nurse fills out an adverse drug reaction form that the pharmacist reviews and uses in launching an investigation.

For example, Northern Arizona Homecare has home infusion clients, and sometimes one of those patients will experience a skin rash or begin vomiting after being started on a new medication. When this happens, the nurse completes the adverse drug reaction form, gives it to the pharmacist, and the pharmacist begins the investigation by calling the patient’s physician.

The pharmacist determines whether the patient truly had an adverse drug reaction, and if so, then the case is reported to the FDA.

Even minor drug reactions are investigated. Wellborn once had a patient who was receiving a medicated infusion. The patient felt fine, but whenever Wellborn started the infusion, the patient began to hiccup. Although the hiccups certainly weren’t life-threatening, Wellborn filled out an adverse reaction form and gave it to the pharmacist. The patient’s physician told the pharmacist that it could be due to the medication, and the pharmacist researched the drug further and determined that the hiccups were caused by the drug. However, as long as the patient didn’t mind the hiccups, the agency continued the medication.

Monitor patients’ medication issues. The agency’s pharmacist calls infusion patients regularly to ask how their supplies are holding out and how they’re doing on the medicine. Usually the pharmacist places those calls each week, but sometimes more frequently, Wellborn says. "The pharmacist is talking to one caregiver every three to four days because the patient is very ill."

Since the pharmacist has computer access to the patient’s visit notes and medical information, those calls give the pharmacist an opportunity to update any information. Also, the pharmacist regularly receives a copy of all laboratory reports of patients.

The pharmacist’s monitoring practice helps the agency improve the quality of care and it prevents waste, Wellborn says. "We’ve had a couple of situations where we needed to use an out-of-town pharmacy for Medicaid patients. So, that pharmacy has to ship the medication supplies to the patient’s home, and it may or may not get there."

These other pharmacists may never call to check to make sure the patient has the correct amount of medication, and so there often is a waste, particularly when the physician changes the medication, and the pharmacy had already sent a large supply of the old drug. Northern Arizona Homecare’s pharmacist keeps close tabs on the medication supply, so those problems do not occur when the agency’s pharmacist is handling the case.

Joyce Eland, BSN, Quality Manager, Visiting Nurse Association of Johnson County, 2953 Sierra Court, Iowa City, IA 52246. Telephone: (319) 337-9686. Fax: (319) 337-5566.

Pat Lucker, RN, Quality Manager, Gritman Home Health, 700 S. Main St., Moscow, ID 83843. Telephone: (208) 883-2237.

Loretta Wellborn, RN, MS, Director, Northern Arizona Homecare, 1200 N. Beaver St., Flagstaff, AZ 86001. Telephone: (520) 773-2238.