Medication errors happen to be source of significant morbidity and mortality in hospitalized patients. Medication errors are preventable incidents that occur due to an error in the process of prescribing, dispensing, and administrating. Severe cases often lead to malpractice claims. This paper examines medication errors in hospitals. The risk factors for medication errors is also discussed as well as proposed strategies to counteract them. Focus is placed on hospitals as they tend to be the main source of medication incident reporting. In the advent of technology, the medication administration environment is becoming increasingly complex. Given the complexity of medication therapy, it would be possible to reduce most error but impossible to avoid all error.
Keywords : medication errors, adverse event, patient safety
Medication Errors in Hospitals: Potential Risks and Prevention Strategies
The story of Josie King is one that shook the hospital health care system in 2001. Josie King was an 18 month-old that died from complications of treatment at Johns Hopkins Medical Center. Josie was originally admitted to the hospital with second and third degree burns over 60 percent of her body. During care, Josie had received a lethal dose of methadone after which she died as a result of a cardiac arrest. As a result of this sentinel event, the Kings were awarded a settlement which they refused. Josie's mother Sorrel wanted everyone to know what happened to her baby. Sorrel King has written an inspiring memoir "Josie's Story" and has created a patient-safety program at Hopkins in addition to a foundation devoted to reducing medical errors. Sorrel King now advocates for patient and families affected by medical errors, and provide lectures to medical professionals countrywide. (www.josieking.org.)
Medical errors have and continue to be an enormous problem in health care. Patients die from the wrong drug or wrong dosage, or perhaps an infection that could have been prevent with better hygiene practices. More attention was placed on the issue of medical errors in 2000 when the Institute of Medicine made available the well-known report "To Err is Human: Building a Safer Health System". The report documented evidence of an estimated 44,000 people and as many as 98,000 people dying in hospitals from medical errors each year in the United States (IOM, 1999). Of the many medical errors, medication errors happen to be one that can not be overemphasized. Medication use have been found to account for at least 20 percent of adverse events in patients in hospitals. Out of every hundred medication orders, there is an occurrence of five adverse drug events (Tam, 2005).
Malpractice claims due to adverse drug events can have negative effects on the hospital and the health care providers. The hospital and health care providers can have their reputation damaged, thousands of dollars are spent for the losses, there is time lost from work, not to mention the emotional stress involved (Rothschild et. al, 2002). The cost of preventable medication errors has been estimated between 17 and 29 billion dollars annually (Strohecker, 2003). As such, due to these alarming statistics, this paper focuses on some of the potential risks of medication errors, and some recommended interventions that can be implemented to help curb the incidence of medication errors.What is a medication error?
A medication error is defined as "any preventable event that may cause or lead to inappropriate medication or patient harm while the medication is in the control of the health care professional, patient, or consumer" (Oren, 2003). The terms adverse drug events and medication errors though used interchangeably do not necessarily mean the same thing. An adverse drug event is an undesirable reaction after a drug administration that is not necessarily caused by the drug. Adverse drug events include adverse drug reactions and medication errors. Medication errors may lead to actual or potential adverse events. The potential adverse events are often termed "near misses". For example, if a medication overdose is administered accidentally, it would be a medication error and not described as an adverse drug reaction (Oren, 2003).Potential Risks of Medication Errors
Many of the factors leading to medication error are unfortunately human related (Etchells, et. al, 2008). A survey of 983 nurses working in acute care hospitals reported that among the many factors that would contribute to medical errors, illegible hand written prescriptions, distraction from the environment, exhaustion and stress happened to be the most weighted (Mayo & Duncan, 2004). A study by Hodgkinson et.al that sought strategies to reduce medication errors cited the most common reason of medication error was due to the lack of drug information by the multidisciplinary team (2006). Inexperience and or lack of knowledge of the drug could lead to the physician ordering the wrong dose, the pharmacist incorrectly mixing the medication with the right concentration, and the nurse administering the medication with the wrong route such as giving an intramuscular injection instead of subcutaneously (Etchells, et. al, 2008).
While human error is very important to consider, it is equally important to analyze the context in which errors can occur such as the clinical environment and patient population. The type of clinical setting in a hospital can be more prone to medication errors than others due to the patient population with respect to the severity of their illness, and number and type of medications needed to be administered. Critical care units for example, tend to be at a higher risk for medication errors. Critical care units provide for very sick patients who need to be attended to without delay, may require consults from various providers, and receive twice as many medications as compared to patients on general medical floors. Patients in intensive care experience an average of 1.7 medical errors each day. Medication errors are the most common type or error and account for 78 percent of serious medical errors in critical care (Camire et. al, 2009).
In addition to the patients in critical care, pediatrics and the elderly also tend to be at high risk for medication errors since there require many medications when sick. Pediatric patients in particular tend to be very sensitive to most medications hence the need to calculate most of their medication dosages by weight (King, 2003). The least miscalculation could lead to an adverse drug event. Older adult populations, on the other hand, take many prescription medications for their chronic illnesses which need scrutiny to avoid contraindications (ANJ, 2009). However, regardless of whether the patient may be at risk of experiencing a medication error or not, all medication administration must ideally follow the "seven rights" which include "the right patient, right medication, right dose, right time, right route, right reason, and right documentation" (Schaeffer, 2009).
Another factor which may influence the safety of medication administration involves medication reconciliation. When patient's list of home medications and allergies are not collected upon admission, a medication error can occur when a medication being taken regularly at home is not continued during the hospital stay. If the patient's medication reconciliation is not complete, the physician would not have full knowledge of the medications that the patients would need to be restarted on after being transferred or discharged from the hospital. At times there may be an oversight on the part of the prescribing physicians where brand and generic medication names are concerned. A physician may also duplicate order a medication that the patient may already be taking at home, and at times order an incorrect dosage (Landro, 2006).
In recent times, there have been technological influences in health care, where there has been an effort to get rid of the paper documentation but the transition is not that complete. Many hospitals still document on paper and still creating the risk of medication errors by the use of error prone medication abbreviations. During transcription of written orders, the use of abbreviations can cause errors if not interpreted correctly. In a study discussed in the Joint Commission Journal on Quality and Patient Safety, medication errors that were reported to the national database made up 5 percent of all errors that occurred as a result of incorrect interpretation of abbreviations used during prescribing. In the study, an analysis of 30,000 abbreviations related- medication errors reported to the United States Pharmacopeia's database was made. Most of the errors consisting 81 percent were made during the writing of prescriptions. The abbreviation "QD" used in place of "once daily" was found to have caused more errors; 43.1 percent than any other abbreviation. The Joint Commission has a national safety goals report that include a "do not use" list of abbreviations that hospitals and other healthcare organizations can use as a reference (Joint Commission, 2006)Medication Error Risk Reduction Strategies
In addition to the "seven rights", hospitals are instituting additional evidence-based practices. According to The Joint Commission Journal on Quality and Patient Safety, the implementation of "six best practice" procedures for medication administration designed by the California Nursing Outcomes Coalition (CalNOC) significantly improved accuracy (2009). In this study, participating hospitals showed an 80.5 percent improvement in adherence to CalNOC best practices and an 81.4 percent score for combined administration accuracy and best practice improvements. The CalNOC six best practices include: "compare medication to medical record, keep medication labeled until administration, check two forms of patient identification, immediately record medication administration in the chart, explain the medication to the patient, and minimize distractions and disruptions during the administration process" (Joint Commission Journal, 2009).
Another technological invention to help reduce medication errors are the smart infusion pumps. These smart pumps have built-in danger alerts, clinical calculators, and drug libraries including information on the standardized concentrations of commonly used drugs. Though smart pumps have been designed to prevent mistakes, it only works for high alert intravenous medications. In cases where the smart pumps are not used appropriately, its purpose is not served. In a controlled trial study of smart infusion pumps, nurses were found to "routinely ignore danger alerts and drug libraries as much as 25 percent of the time, sometimes administrating medications such as propofol, insulin, and heparin at rates 10 times as high as those ordered" (Rothschild et.al, 2005). Smart pumps can work exceptionally and prevent errors if alerts are paid attention to used appropriately.
The computerized physician order entry (CPOE) system is another technology that has been found to significantly decrease the danger of illegible handwritten orders and the need for transcription. According to Bates et. al, out of the approximately 28 percent of preventable adverse drug events are associated with medication errors, 56 percent occurred during prescribing (Bates, et. al, 1998).The computerized physician order entry (CPOE), computer based system where all orders are electronically written helps to ensure accuracy of writing orders. Most of these CPOE are accompanied by a Clinical Decision Support System (CDSS) which provides automatic alert to prescriber on drugs or doses that are contraindicated with the patient's age, allergies, condition, and or diagnosis. Review of a systematic study by Kaushal et. al on the effects of CPOE with CDSS showed a considerable decline in the rates of medication errors (2003).
A study at the Brigham and Women's Hospital in Boston on the effect of CPOE on prevention of serious medication errors showed that using a POE system prevented more than half of the serious medication errors. There was a reduction in all the stages of the process; from ordering to dispensing to administration (Bates et.al, 1998). The beneficial effects of CPOE systems would extend beyond medication safety and include reduced cost and quality improvement. CPOE therefore holds promise as an intervention to improve patient safety but would require further data of the benefits of costs before implementation.
Bar coding is another technological intervention that has been shown to decrease the rate of medication administration errors. Bar coding can alienate the possibility of nurses administrating medications without having a documented order. With bar coding, each time a physician ordered a medication, the order is automatically transmitted to the pharmacy where a unique bar code is generated. After verification of the order by the pharmacist, the labeled medications are sent to the floor/unit. The nurses who have to administer the medication would then have to scan the bar code on the patient identification band against the labels on the medications for comparison.
Bar coding has reduced medication errors by more than 50 percent, preventing approximately 20 adverse drug events per day (Poon, 2005). The Veterans Affairs hospital led the way in 1999 instituting a national bar coding program. Within a year of initiation the VA hospital documented a 24 percent decrease in the rate of medication-administration errors (Wright et. al, 2005). Although the ultimate goal is to protect patients, bar coding could also save hospitals lots of money. The average adverse event costs extra hospital days and additional services, not to mention the cost of litigation. Like every other measure there would be disadvantages for using bar coding, but once more research can show that the benefits outweigh the costs, more hospitals can join the increasing number of institutions that have embraced this technology.
With medication errors responsible for many lost lives yearly, new national patient-safety standards require hospitals to have a mandatory formal medication reconciliation process for every patient admitted into the hospital. Medication reconciliation would take effect during the patient's admission process and involves the collection of a complete drug and allergy history comparing them with new medications that he physicians order. This routine has been found to reduce medication problems while the patients are admitted and when they are discharged with new drug regimens. This process is does not work if efforts are also not taken to educate patients and families on the importance of maintaining a personal up-to-date medication and allergy list and being able to provide that list in emergent situations (Landro, 2006).
This paper has reviewed research on medication errors in hospitals with an emphasis on the prevalence, risk factors, and strategies to prevent errors from occurring. Although the immediate cause of medication errors is often as the result of human error, the majority of errors can be attributed to system failures made worse by the increasing complexity of patient care. A medication error can cause devastating results, threaten patient's lives, and affect a provider's confidence and job security. Hospitals also tend loose lots of money in malpractice law suits. The wide range of pharmaceutical products and dramatically changing technology adds to the complex situation. Many strategies including the CPOE and CDSS, smart pumps, and bar coding among other strategies have already been implemented by few hospitals. Research shows that these strategies that have been implemented targeting the reduction of medication errors have been found to be promising. However, due to the complexity of patient care, both human and technological influence may be able to control but never be able to completely put to death medication errors.