Medication Errors in Hospitals: An Analysis

Reducing medication errors hasbecome a topic of top priority inour nation, with primary emphasison improving patient safety. Accordingto the National CoordinatingCouncil for Medication Error Reportingand Prevention, a medication error isdefined as a "preventable event thatmay cause or lead to inappropriatemedication use orpatient harm while the medicationis in the control of thehealth care professional,patient, or consumer."¹ Just asdrugs can save lives, they canlead to harmful events affectingnot only the patient, butalso health care in general.

An array of studies hasaddressed the subject, as alarge number of Americansdie each year due to medicationerrors. In fact, accordingto the report of the Instituteof Medicine (IOM) entitled"To Err Is Human: Building aSafer Health System," between44,000 and 98,000 peopledie in hospitals as a resultof medical errors, which, accordingto major studies, could havebeen prevented.²

For decades, minimizing adversedrug events and medication errors hasbeen a goal in health care. Nevertheless,it is highly recognized that competentand caring professionals willmake mistakes. When analyzing medicationerrors, the trend in the past hasbeen to place possible negligence onthe health care provider. Yet, today werealize that many medication errorsresult from inadequate systems leadingto serious mistakes by providers.

Errors can occur during any stage ofthe medication process. Rather thanupholding a punitive approach, however,now the focus is to concentrateon "prevention" and to devise strategiesto minimize errors and adversemedication events. Although providersare still held to a high standard andmust be responsible for the decisionsthey make, placing blame on an individualseldom leads to positive outcomes.

Medication Errors?An Overview

In an article published in the Journalof Clinical Pharmacology, David M.Benjamin, PhD, FCP, outlines "5rights" in delivering drug therapy: (1) theright drug, (2) the right dose, (3) theright route, (4) the right time, and(5) the right patient.³ Yet, the system isfar more complex. The incidence ofmedication errors in hospitals is at anall-time high, resulting in hospitaladministrators exploring new interventionsconducive to an overallimprovement in safety.

The report from the IOM states thatpatient awareness, based on patienteducation prior to discharge, also canprovide a "major safety check" in hospitals.The aim is for patients tobecome familiar with the appearanceof their medication, possible sideeffects, and the purpose for taking themedication?in essence, to create anawareness and a proactive approach totherapy on the part of patients.

Factors Contributing to Errors

The work environment in generalcan lead to errors?interruptions, aninadequately trained staff, sleep deprivation,language barriers, medicationsound-alike names, and lack of dataconcerning a patient can become risks.A recent review article, "MedicationErrors: A Bitter Pill" by Kathleen C.Ashton and P. W. Iyer of RutgersUniversity, outlines certain factors thatlead to adverse medication events⁴:

• Ordering errors. These errors occurwhen the physician orders thewrong drug, wrong dose, a drug towhich a patient is allergic, or duplicationin therapy. The nurse maythen perpetuate the error by notquestioning the physician. In addition,handwritten prescriptionscan lead to catastrophic results,due to sloppy handwriting andconfusion about decimal points.
• Administering errors. These errorsencompass the wrong drug, thewrong patient, and the wrongroute. A common error in hospitalsinvolves patient-controlled analgesiapumps. Although the advantageof the pump is the ability ofthe patient to obtain the rightdose, if the pump has not beenprogrammed correctly the patientmay risk serious side effects.
• Transcription errors. Entering incorrectdata onto the medicationadministration record by nonmedicalpersonnel can be a factor.Thus, nurses on duty need to havesystems in place to detect potentialerrors.
• Dispensing errors. Many of theseerrors involve the pharmacy's supplyingan incorrect medication ordose; or they may occur when thepharmacy is closed. In her study,Dr. Ashton reported that the JointCommission on the Accreditationof Healthcare Organizations nowdiscourages access to the pharmacyby nurses after the pharmacy isclosed.⁴

Implementing Crucial SystemsNationwide

Hospitals nationwide are exploringand developing systems for the purposeof reducing medication administrationerrors. The Valley Hospital, a451-bed acute care facility in NewJersey, has worked diligently in developinga system to reduce medicationadministration errors. M. Mutter, ofClinical Systems and Quality Improvement,has determined certainfactors that are necessary to achievinggoals, namely (a) becoming familiarwith the actual errors?concentratingon how, when, and why they werecommitted; (b) establishing a "nonpunitive"(whereby no punishment ordisciplinary action is imposed for anyspecific error) approach wherebyreporting of errors or "near-misserrors" (a process variation that doesnot affect an outcome but for which areoccurrence carries a significantchance of a serious adverse effect) isencouraged; (c) identifying areas ofconcentrated errors; (d) standardizingsteps in the identification of errors;and (e) selecting the proper technologyto correct these errors.

A medical facility that represents amodel in the area of reducing medicationerrors is the Kendall RegionalMedical Center in Miami, Fla. KendallRegional is highly committed to protectingpatients and their well-being.Ana Caldera, director of pharmacyservices, describes the system as onethat prevents errors generated "fromthe dispensing as well as the administrationend."

Kendall Regional has gone to greatlengths to institute a system thatencompasses a pharmacy robotics systemto automate the dispensing ofinpatient medications, as well as a barcodeelectronic medication administrationsystem that ensures accuracy inadministering the correct medicationto the right patient, in the rightdosage, and at the right time. Whereasmany institutions utilize one or theother of these systems, Dr. Caldera hasstated that Kendall Regional is the onlyhospital in South Florida that usesboth systems in tandem to ensure optimalpatient safety.

The robotic system at Kendall iscalled Serving Patients on Command(SPOC). Peter Jude, director of marketingand public relations at Kendall, hasexplained that each medication is preparedfor the system by separating itinto an individual unit dose. It is thensealed in an individual bag, labeledwith a specific bar code, and preparedfor retrieval and dispensing by SPOC.

The nurse on call later scans the barcode on the unit dose and matches itwith the patient's bar-coded identificationwristband. The verificationprocess is performed via the "ElectronicMedication AdministrationRecord" to confirm that the medicationis what is to be administered tothe patient. Whereas Kendall Regionalhas devised its own effective system,many institutions nationwide haveimplemented ways to dispense medicationwith little or no error.

Role of the Pharmacist in PreventingAdverse Drug Events

The role of the pharmacist in reducingmedication errors has been emphasizedin various studies. A study conductedby Drs. La Pointe and Jollis, ofthe Division of Cardiology at DukeUniversity Medical Center, found thatmany medication errors have occurredin hospitalized cardiovascular patients(eg, the wrong drug or dose).⁵ Theauthors concluded that the participationand contributions of a pharmaciston rounds have resulted in a decreasein errors. The value of a pharmacist onboard was reiterated in a study by theDepartment of Pharmacy Services ofHenry Ford Hospital, which found thatthe role of the pharmacists on roundsalso has had a positive effect on preventingadverse drug events.⁶

Conclusion

Certainly, reducing medicationerrors requires a process that identifieswhere most errors occur and thatimplements a quality improvementsystem to minimize the risk of errorsand develop the means to make adequatechanges. The emphasis onreporting errors by employees in agood-faith, nonpunitive environmentwill lead to improved patient safety.

Dr. Pelegrin is the pharmacy manager of aPublix Pharmacy in Miami, Fla.

For a list of references, send a stamped,self-addressed envelope to:References Department, Attn. A. Stahl,Pharmacy Times, 241 Forsgate Drive,Jamesburg, NJ 08831; or send ane-mail request to: astahl@mwc.com.