Medication Errors

Detect errors, then take systemic action

Awareness growing, but mistakes still happen

Ken Barker, PhD, of Auburn (AL) University's department of pharmacy care systems, says the keys to error prevention are direct observational studies of a hospital's medication practices and development of systemwide approaches. Nonetheless, many hospitals are reluctant to undertake these efforts, he says, primarily because of the perceived costs.

Hospitals will soon be required to present quantitative evidence of the quality they deliver if they are not already doing it. For the first time, there will be a positive economic incentive for learning how to detect and prevent errors. But the price tag still looks high to hospitals. In a time of cost squeezes, well-intended attempts to re-engineer the medication system are often downgraded to a risk management approach that looks only at highly visible areas. If the only errors studied are those that hurt patients, rather than all system failures regardless of outcome, you have a risk management approach. That approach is important in assessing the significance of a situation, but it's less effective for deciding how or what to do about it.

'Rational and objective' discussion needed

Most errors are system problems, so the most effective way of reducing the error rate is to improve systems, Barker notes. "What's most encouraging is the fact that medication errors can now be talked about in a rational and objective way - the quickest road toward the real changes needed."

"When we first started in 1975," says Michael Cohen, president of the Warminster, PA-based Institute for Safe Medication Practices (ISMP) in "we used to get hate mail from hospitals saying it was just careless individuals who made errors and that the public will be scared to come to the hospital." He says there's been a turnaround and he now sees an interest in improving systems so they are not set up to allow errors.

Most incidents are avoidable. One-third of medical error deaths, for example, are attributed to the inadvertent IV injection of potassium chloride. (See article about KCl-related risks, Hospital Peer Review, June 1998, p. 101.)

"When a serious error does happen and organizations come to investigate," Cohen says, "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 he'd like to see accreditation standards require such disclosure, but new policies fall short of that. (See coverage of the Joint Commission's sentinel events policy in Hospital Peer Review, May 1998, p. 85.)

Industry professionals have talked about doing something about medication errors for more than two decades, but now a number of initiatives and technologies are converging to create some substantive inroads.

Cohen is encouraged by FDA consideration of policies that would test the confusion factor of the names, packaging, and labeling of new drugs before coming to market, which contributes to 50% of medication errors. "I can predict with over 90% certainty what product mix-ups will happen just based on the name," he says. The ISMP has a system that flags this type of problem, and it is available to drug companies. "It's not expensive," says Cohen, "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 current plans to do so.