Roundup: Preventing Medication Errors in Health Systems

Mr. Nelson is a PharmD candidate atThomas J. Long School of Pharmacyand Health Sciences, University ofthe Pacific in Stockton, California.Dr. Nguyen is a clinical pharmacistat Fountain Valley Regional Hospitalin Fountain Valley, California. Dr.Pham is assistant professor of pharmacypractice at Western UniversityCollege of Pharmacy and HealthSciences, in Pomona, California.

When the Institute of Medicine(IOM) released To Err isHuman—its series of reportsexamining the quality of health carein the United States—these reportscaught the public's attention morethan other health policy issues in thepast.¹ Congress scheduled hearings, andPresident Clinton called on federal agenciesto implement the IOM's recommendations.² The reports addressed 4major issues: (1) errors are commonand costly; (2) systems cause errors; (3)errors can be prevented, and safety canbe improved; and (4) patient safety mustbecome a national priority.

Types of Medication Errors

According to the Joint Commissionon Accreditation of Healthcare Organizations,the inpatient medication managementprocess has 6 major steps:selection and procurement, storage,ordering and transcribing, preparing anddispensing, administration, and monitoring.³ Although errors can occur duringany step of this process, a logical firststep is to target the processes wheremost errors occur. MEDMARX, the USPharmacopeia's national database formedication errors, reveals that mostmedication errors (30%) occur during theadministration stage.⁴ The prescribing,transcribing, and dispensing stages wereeach responsible for >20% of all medicationerrors (Table 1).

Table 1

Source of Medication Errors

Stage

Percentage of errors

Administering

30

Dispensing

26

Prescribing

22

Transcribing/documenting

21

Monitoring

<1

Adapted from reference 4.

According to a study that examinedthe frequency and variety of medicationerrors in 36 health care facilities (24 ofwhich were hospitals), the most commoncategory of error, besides "dose administeredlate," was omission error (30% of allerrors), meaning an ordered dose of medicationwas not given to the patient. Othercommon errors were "wrong dose" given(17%) and "unauthorized drug" given (4%).It also was found that a medication errorwas made in about 1 of every 5 orderswritten (~20%).^5,6

Most errors can be attributed to theperformance deficit of a health care professional,meaning that the professionalpossesses the knowledge and trainingto carry out his or her duty but fails todo so.⁴ Breakdowns in communicationamong health care team members alsocan be a problem. These include the useof unapproved abbreviationswhen writingorders, unclear writtenor verbal orders leadingto inaccurate interpretations,or mix-ups withlook-alike and soundalikemedications.⁴Although it may benearly impossible for ahospital to ensure eachemployee has and usesthe same level of professional judgment,it is feasible to improve communication.

The Role of Technology

About 39% to 49% of medication errorsoccur during drug ordering, according toone recent study.⁷ Electronic medicalrecords (EMRs) have been successfulin reducing these errors. Health careproviders can access a patient's medicalrecords to view demographics, medicalhistory, progress notes, laboratoryand procedural results, and medications.One study found that EMRs reduce medicationerrors by 55%, compared withpaper-based systems; however, anotherstudy found that <25% of US hospitalsand 20% of physician's officesuseEMRs.⁸ Ideally, an EMR replaces papercharts; if hospitals do not fully implementa paperless system, however, an EMR cancoexist with paper charting.

Another technology similar to EMRis computerized physician order entry(CPOE), which allows physicians to ordermedications by selecting the drug anddosage listed on a computer screen. Onestudy found that CPOE reduces medicationerrors by up to 81%.⁹ A survey-basedstudy revealed, however, that, of662 respondents, only 17.4% were usingCPOE.¹⁰

For paper-based systems, letterboxand preprinted order forms are useful toalleviate illegibility. For medications withmultiple indications, requiring physiciansto write indications can assist pharmacists in assessing appropriatetherapy. Also, preprinted order sets based on published guidelinesare recommended for such diagnoses as community-acquired pneumonia,acute myocardial infarction, and patient-controlled analgesia.

Health systems also should take care to avoid the use of unapprovedabbreviations, trailing zeros, and lack of verbal/telephoneorder read-backs. Health systems that post a list of unapprovedabbreviations throughout the hospital have been successful inreducing errors. To enforce compliance, pharmacists should sendback incomplete orders with unapproved abbreviations, "prn"orders without indications, or verbal/telephone orders withoutread-back documentation.

Medication Reconciliation

Medication reconciliation is usually performed to ensure thatpatients continue to receive medicines they were taking prior toadmission or transfer into another health system unit. More thanhalf of medication errors occur while patients are in transition.¹¹According to one study, when adult patients left the intensive careunit, medication reconciliation eliminated nearly all errors.¹¹

Health systems pharmacists who perform daily patient profilereviews also have seen success. Having pharmacists review patientdiagnoses, medication profiles, and laboratory profiles for therapyduplications, drug?drug interactions, dose adjustments, and appropriateantibiotic coverage, has reduced errors significantly.

High-alert Medications

In other studies, nursing administration accounted for 26% to38% of medication error occurrences in hospitalized patients.^2,6,7High-alert medications should require a double-check and a timeoutat bedside; they require 2 registered nurses' signatures on themedication administration record before dispensation. Also, chemotherapiesrequire a time-out to check the 5 rights of medicationadministration (Table 2) and patency of intravenous lines.

Table 2

5 Rights in Medication Delivery

1. Right Patient

2. Right Drug

3. Right Dose

4. Right Route

5. Right Time

Infusion pumps account for up to 35% of errors, in which the mostcommon cause is incorrect manual programming.¹² Smart pumptechnology is capable of warning nurses when an error occurs.¹³

Bar coding has been useful in reducing medication errors.Veterans Affairs hospitals saw an 86% reduction in errors afterimplementing bar coding.⁷ Ideally, bar coding interfaces with EMRsand pharmacy systems, so when an order is written, checkedagainst EMRs, processed, and labeled by the pharmacy with apatient's unique bar code, the nurse can scan the medication labeland the patient's wrist band to assure the 5 rights are met.⁸

Conclusion

Education and technology, such as CPOE, bar coding, smartpumps, as well as adverse drug event reporting, all contribute tomedication safety.⁶ Everyone involved in patient care must workto prevent medication errors from occurring.

References

• Altman DE, Clancy C, Blendon RJ. Improving patient safety ? five years after the IOM report. N Engl J Med. 2004;351:2041-2043.
• Leape L, Epstein AM, Hamel MB. A Series on Patient Safety. N Engl J Med. 2002;347:1272-1273.
• The Joint Commission on Accreditation of Healthcare Organizations (2007, December 17). Joint Commission on Accreditation of Healthcare Organizations: Critical Access Hospital 2006 Medication Management. www.jointcommission.org/NR/rdonlyres/E6504BF2-E51E-4141-8777-E61380C10B91/0/06_cah_mm.pdf. Accessed December 23, 2007.
• Santell JP. Medication Error Prevention: Pearls for Health-System Pharmacists and Nurses. http://symposia.ashp.org/mederrors/overview.html. Accessed December 22, 2007.
• Barker K, Flynn E, Pepper G, Bates D, Mikeal R. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002; 162:1897-1903.
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• Jayawardena S, Eisdorfer J, Indulkar S, Pal SA, Sooriabalan D, Cucco R. Prescription errors and the impact of computerized prescription order entry system in a community-based hospital. Am J Therapeutics. 2007;14(4):336-340.
• Inquilla CC, Szeinbach S, Seoane-Vazquez E, Kappeler KH. Pharmacists' perceptions of computerized prescriber-order-entry systems. Am J Health-Syst Pharm. 2007;64:1626-1632.
• Weitzel KW. Medication Reconciliation. Pharmacist's Letter. 2006;22:#220513.
• Rosenthal K. Smart pumps help crack the safety code. Nurs Manage. 2004;35(5):49-51.
• Husch M, Sullivan C. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Qual Saf Health Care. 2005;14:80-86.