Only human’ is no excuse for medication mistakes

Goal toward zero tolerance desirable

A year ago, a report issued by a federal advisory panel reported that up to 98,000 people die each year in the United States from preventable medical errors. About 7,000 of those deaths were due to medication mistakes. The announcement was not a surprise to many who work in the field of medicine; in fact most health care facilities have been diligently working on correcting the problem.

"We don’t just count the number, we have a zero tolerance for all medication errors, and try to look at why it happened and remove the possibility of it ever happening again," says Debra Hollenberg, MSN, quality manager in the nursing division at New York Presbyterian Hospital in New York City. To avoid errors, education of both staff and patients is needed, she says.

Analyzing the data on inpatient medication errors, Hollenberg determined that at her institution, about a quarter are physician-related with the medication order written incorrectly, another 25% are pharmacy errors, and about 50% are errors in the administration of the medications.

To help prevent human errors, New York Presbyterian Hospital began to embrace technological solutions; but with the conversion came the need for staff training. New systems implemented include computerized order entry and automated medication dispensing. The order entry system has built-in physician alerts that flash warnings when there is a problem.

For example, the patient may be allergic to the medication, or the dose may be too high for the patient’s weight. It also eliminates errors made when the order is transcribed onto the medication record because it automatically transfers to
a computerized record.

The automated dispensing system contains patient profiles, and will not dispense the medication for a patient unless pharmacy reviews the order. Automated dispensing systems, physician order entry and computerized medication records have reduced medication errors by 50% since 1996, says Hollenberg. However, she believes that patients and family members need to be proactive and learn what medications have been prescribed so that they can make sure they are taking the right ones.

Following a study at Northwestern Memorial Hospital in Chicago, pharmacists are being asked to go on rounds with a medication error prevention mindset. "The study showed that if a pharmacist goes on rounds, we could reduce errors and the duration of errors by at least half," says Michael Fotis, RPH, manager of drug information at the pharmacy.

During the study, one group of patients received usual care, while a second group received usual care with the addition of a pharmacist on rounds. One of the major errors uncovered by the study was the oversight of consultant’s recommendations. When a consultant saw a patient and recommended a medication, it wasn’t always ordered, explains Fotis. "Now we know to have our pharmacist check all consult orders to make sure that if they aren’t picked up it is intentional," he says.

Controlling outpatient mistakes

Medication errors are not limited to inpatient care, and can be the reason for many hospital admissions. Northwestern investigates about 100 adverse drug reactions a month, and finds that the No. 1 mistake people make is taking a nonprescription product that is actually the same as their prescription, which results in an overdose.

Another is changing the medication dose of a long-acting drug without consulting their physician, says Fotis. "We found that patients were taking some extra doses because they thought their symptoms of illness were returning and it would help them. Also, they didn’t know important symptoms of toxicity, and that they should call their doctor at once if they had the symptoms."

Education is key in reducing those medication errors, says Fotis. At Northwestern, all patients started on warfarin receive a consult with a pharmacist before they are discharged, which is about 60 patients a month. Teaching includes information on how to track doses, nonprescription products that can interfere with the medication, and why they shouldn’t make drastic changes in their diet without alerting their physician.

A pharmacist calls the patient twice a week to assess the response to treatment and to reinforce the education. "Patients tell us about their missed doses and diet changes; I don’t think they would do that without good teaching," says Fotis. As a result, the adverse event rate is less than 1%.

Although Hollenberg only gets reports on inpatient risk management medication errors, she is aware of common mistakes patients make when discharged. One is dosing errors, either taking a double dose because they forgot they already took the medication, or forgetting to take the medicine altogether. To prevent those errors, Hollenberg advises educators to suggest patients keep a log, writing the medications down as they take them. "Patients should also make sure they read information that comes with the prescription when they pick up their medications from the pharmacy because it may not have been covered by the nurse before they left the hospital," she says.

Most importantly, patients must be taught to be their own advocate. To avoid problems, they should know to tell the prescribing physician everything he or she might need to know to avoid adverse reactions. That includes any medications or over-the-counter herbal medicines they are taking and any underlying conditions they might have. If breast-feeding, for example, a woman should ask if the antibiotic would affect her breast milk, says Hollenberg.


For more information about avoiding medication errors, contact:

Michael Fotis, RPH, Manager of Drug Information, Pharmacy, Northwestern Memorial Hospital, 251 E. Huron St., Stinberg L-700, Chicago, IL 60611. Telephone: (312) 926-0751. E-mail:

Debra Hollenberg, MSN, Quality Manager, Nursing Division, New York Presbyterian Hospital, 525 E. 68th St., New York City, NY 10021. Telephone: (212) 746-4494. Fax: (212) 746-8421. E-mail: