Medication errors: New initiatives are launched as problems worsen
Medication errors: New initiatives are launched as problems worsen
Awareness is more widespread, but mistakes still pile up
Industry professionals have been talking seriously about stemming medication errors for better than two decades, and it appears that a number of initiatives and technologies are converging to create the first substantive inroads pharmacists have made. There are even some indications that pharmacists finally have adopted the mindset needed to solve the problems.
"When we first started in 1975, we used to literally get hate mail from hospitals saying it’s just careless individuals who make errors and that the public will be scared to come to the hospital, but we’ve seen a complete turnaround and today people are much more sensitized," says Michael Cohen, president of the Institute for Safe Medication Practices (ISMP) in Warminster, PA. "We’re starting to see new effort in bettering the systems so we’re not set up to make these errors."
Adds Ken Barker, PhD, of Auburn (AL) University’s department of pharmacy care systems, "It appears that most errors are system problems and that the most effective way of reducing the error rate is to attack the systems. Certainly what’s most encouraging is the fact that medication errors can be talked about in a rational and objective way, which I think is the quickest road toward the real changes needed."
While there is progress to report, the problem is growing: In 1996, the U.S. Food and Drug Administration’s Medwatch program screened more than 170,000 reports of adverse drug reactions. From 1991 to August 1997, nearly 3,000 medication error reports were given voluntarily to the U.S. Pharmacopeial Convention.
A Harvard study using 1994 numbers estimates that adverse drug events are to blame for more than one million injuries and 140,000 deaths a year. That, by the way, is equivalent to two 747 jets crashing every day for six months and leaving no survivors. A more recent study published in the December, 1997, issue of the Journal of the American Medical Association estimates that one-third of all hospital patients experience some type of adverse reaction to drug therapy.
As of October 1997, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) had reviewed 171 sentinel events under its Accredita-tion Watch program. Medication errors accounted for the majority of those cases, with 36 medication errors leading to 33 deaths.
Disclosure and prevention as key solutions
For Cohen, those numbers are particularly vexing, as one-third of the deaths were attributed to the inadvertent intravenous injection of potassium chloride, one of the more dangerous and frequent errors ISMP has publicized.
"When a serious error does happen and organizations come to investigate, it’s extremely frustrating that they don’t use that information to benefit other pharmacists and hospitals, because we see repeat errors over and over," he says. Cohen says he’d like to see accreditation standards requiring such disclosure, but new JCAHO Accreditation Watch policies fall short of his desires. (See story on those new policies, p. 41.)
Cohen is encouraged by initial FDA consideration of policies that would test the confusion factor of the names, packaging, and labeling of new drugs before coming to market, items he says contribute to 50% of medication errors. "I can predict with over 90% certainty what product mix-ups will happen just based on the name; we even have a system that flags this type of problem," he says. The ISMP makes that service available to drug companies. "It’s not expensive, but it does take some time and effort, and we would like to see the FDA push it as a requirement." However, the agency says it has no plans to do so.
For Auburn’s Ken Barker, direct observational studies of hospital medication practices and the development of a systemwide approach are key to error prevention. Nonetheless, many hospitals are reluctant to undertake these efforts, primarily because of the perceived costs, he says.
"But curiously, some hospitals are looking ahead to a time in the very near future when they will have to present quantitative evidence of the quality they deliver. This gives, for the first time, a positive economic incentive for learning how to detect errors and then do something about them," Barker says. "But the price tag still looks high, and in a time of the cost squeeze, what are initially well-intended attempts to re-engineer the whole medication system, which is what’s needed, end up being watered down to a risk management approach that just looks at those areas that are highly visible.
"Should one study only errors that hurt someone, or does one need to study all errors where the system fails, every incident of system failure, even though many don’t appear to have a bad effect?
"Studying errors that hurt someone is more of a risk management approach. That approach is useful and important to assess the significance of a situation, but it’s not very good for deciding how or what to do about it."
The Harvard study also noted that 39% of medication errors were due to physician ordering, while 38% fell on nurse administration. Equal numbers of transcription mistakes and pharmacy dispensing accounted for the rest.
Meanwhile, many physicians are leery of automated systems, while studies show that nurses underreport errors based on fears of punitive actions against them. Where does that leave the pharmacist in the war against medication errors? Right up front, according to many.
Founded in 1996 as a consulting firm to help hospitals re-engineer error-prone medication management systems, Bridge Medical Inc. in Solana Beach, CA, has funded a grant to create a fellowship at ISMP, providing a one-year pharmacist training program in adverse drug event prevention and program administration. Bridge also sponsored a medication error seminar at last fall’s national conference of the American Society of Health-System Pharmacists, attended by former U.S. Surgeon General C. Everett Koop.
"Pharmacists have really been trying hard to prevent errors in their hospitals, and they are willing to share information," Cohen says.
"Pharmacists need to be aware of the errors that are out there and follow the literature. Then you simply say to yourself, What makes me think this won’t happen in my hospital?’"
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