Patient Safety
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| Though technology has helped significantly to improve medication safety, the fact remains that human interaction still plays a role. Overcoming human error takes vigilance and a commitment from everyone on a hospital’s staff. Through the implementation and use of proper protocols for everything from infusion pumps to pharmacy computer systems, a safer environment can be created for patients. Another means of mitigating human error is to ensure that health care workers are properly trained on all new technological systems. |
How is your hospital or ambulatory care facility preventing medication errors? A recent Institute of Medicine (IOM) report, “Preventing Medication Errors” (July 2006), estimates that at least 1.5 million preventable medication errors occur each year in U.S. hospitals, and ambulatory and long-term care settings. For hospitals, the IOM estimates that each patient is subject to at least one medication error per day resulting in
$3.5 billion in costs on an annual basis. These “estimates” were made more visible in September with national media coverage of the medication errors that led to the tragic deaths of three infants in an Indiana hospital.
Various technological solutions have been developed to help make care processes efficient and safe. Automated drug dispensing machines, bar coding, pharmacy computer information systems, computerized provider order-entry (CPOE), infusion devices with decision-support software (i.e., “smart pumps”) and other technologies are continuing to evolve at a rapid pace—and pressure is mounting for their adoption.
As a result, hospitals and health systems have adopted some or all of these technologies without the full benefit of in-depth scientific research as to their benefits or pitfalls. Error data submitted to the United States Pharmacopeia (USP), Rockville, Md., through its national reporting program, Medmarx, can provide some evidence of where technology is meeting its promised benefits and where there is room for improvement. Medmarx is an Internet-accessible, voluntary medication-error and adverse-drug-reaction reporting program that incorporates a nationally recognized taxonomy allowing subscribing hospitals and health systems to collect, analyze and interpret adverse drug events and medication errors (www.usp.org/patientsafety/medmarx). Staff involved with purchasing decisions need to know what problems have been reported so they can help their facility build a successful and safe strategy related to the implementation and use of health care technology.
Data findings
Between July 1, 2001, and Dec. 31, 2005, 131,319 medication errors were reported to the Medmarx program that involved certain types of technology (see Table 1).
Errors involving pharmacy information systems were reported most frequently, but had the lowest percentage of harmful and serious errors. In contrast, errors involving infusion pumps resulted in the highest percentage of both harmful and serious errors. Across the three selected technologies, the most frequently reported type of error was wrong dose/quantity involving situations where an incorrect dose, strength or quantity of a drug was stocked in or retrieved from an automated dispensing machine, entered into the pharmacy order-entry system or administered via an infusion pump. The other top ranking frequently reported types of error differed depending on the type of technology used (see Table 2).
Two of the top three most frequently reported causes of error across all selected technologies were performance deficit and not following procedure/protocol (see Table 3 on page 4). Performance deficit errors occur when a person fails to properly perform a task for which he or she had the knowledge and training to undertake. In many cases, this cause of error was associated with other contributing factors—environmental, situational or organizational factors that can influence the likelihood of an error event.
Distractions, workload increase and inexperienced and/or insufficient staffing are frequent contributing factors when performance deficit is cited as the cause.
Not following procedure/protocol also was frequently reported, indicating inadequate awareness or training regarding policies or, perhaps, an indication that policies are unclear or impractical, creating workarounds (i.e., actions taken that fall outside of established procedures).
Other noteworthy causes of error include drug distribution system (53.8 percent for automated drug dispensing machines), indicating process problems with the storage, stocking and transportation of drugs; transcription inaccuracy (30 percent for pharmacy computer systems), indicating that information pertaining to the drug order was inaccurate, incomplete or omitted, which created a problem when the order was entered into the pharmacy computer system; and monitoring inadequate/lacking (16.9 percent for infusion pumps), indicating that a patient’s vital signs and laboratory values were not appropriately checked.
Problems at hand
Automated drug dispensing machine: An automated dispensing device had been incorrectly filled by a pharmacy technician with vials of a concentrated (i.e., 10,000 units per milliliter) form of the blood-thinning drug heparin instead of the lower strength, 10 units per milliliter. The packages for both strengths were nearly identical.
Two excessive doses of the drug were given to a pediatric patient who later began to bleed and required a transfer to the pediatric intensive care unit for additional treatment and an extended hospitalization.
Pharmacy computer system: The pharmacy received a handwritten prescription for blood pressure medication. The strength of the drug was written as 12.5 milligrams, but the pharmacy computer defaulted to the most commonly prescribed dose of 25 milligrams. The pharmacist edited the order entry by backspacing over the dose and typed in 125 milligrams but forgot to include the decimal point. The dose was printed as 125 milligrams on the pharmacy label and the nurse’s medication administration record. The patient was given a 10-fold overdose.
Infusion pumps: A 3-channel IV pump was used to administer a sedative and an antibiotic to a patient who was on a mechanical ventilator. A nurse inadvertently programmed the IV pump to deliver the sedative at 200 milliliters per hour, which was the rate intended for the antibiotic. The patient received 33 milliliters of the sedative before the ventilator alarm sounded and the error was discovered. The patient required additional medical treatment, but fortunately recovered.
Errors occur in a manual system for many reasons, including illegible handwriting, use of abbreviations, insufficient knowledge of drug-drug interactions, allergies, contraindications and dosage calculations. While some technologies have improved various aspects of medication safety, they also have led to unforeseen errors and even patient harm. Computer order-entry systems that do not cover all components of the medication use process and/or have poorly designed data entry screens, drug-dosing defaults and clinical decision support rules may introduce certain types of errors (e.g., wrong dose/quantity or wrong drug) into the process. Full benefits derived from IT will not be reached unless IT approaches are:
- Fully integrated across all aspects of the medication use process, from prescribing to drug administration
- Associated with common clinical decision support rules between departmental systems (e.g., CPOE, pharmacy, and lab systems)
- Achieve balance between the level of clinical decision support (e.g., alerts and warnings) offered and the amount of decision support that a clinician will realistically use or need
- Developed with attention to sufficient time and resources for staff training.
To uncover IT shortcomings, all programs should be carefully pilot tested to ensure that errors are truly averted and not perpetuated within the system. In addition, computer entry tasks should be viewed as serious, cognitive actions, often requiring clinical judgments.
Health care workers are often interrupted and frequently perform simultaneous tasks such as answering phones or talking directly with others. To prevent errors during computer order-entry, health care professionals should be sufficiently insulated from distractions and interruptions and adequately trained on the system’s functionality with a critical eye toward its limitations and error potential.
Not all IV pumps and automated drug dispensing machines are alike and each model presents various safety features, as well as the opportunity for new errors. Many errors arise when staff override the equipment’s safety features or when staff circumvent operating procedures to save time when faced with emergencies, staffing shortages or excessive workloads.
Organizations need to evaluate their policies and procedures for device use to ensure they are written in a manner ideal for work situations rather than what is more typically seen for their facility.
In general, many of these devices should reduce the incidence of medication errors when interfaced with other hospital information systems and when they are linked to a machine-readable coding system (e.g., bar coding). Organizations using automated drug dispensing machines should:
- Establish use and access requirements, delineate responsibilities for oversight and periodically conduct safety checks to ensure that devices are used and maintained as intended.
- Develop effective policies and procedures that address setting limits (who, what, when and where) around accessing medication; establishing structured procedures for replenishing a device’s inventory and training dedicated staff to perform this function; ensuring that unused medications returned to the device are handled appropriately; and regularly reviewing the appropriateness of the medications being accessed via these devices. Products that may be inappropriate for automated dispensing machines include those with a short shelf life, multidose containers used for more than a single patient and products that require special storage.
Human interaction with technology needs to be studied further to bridge gaps that compromise safety. Manufacturers must include human factors, engineering concepts and expertise in the design phase and should undertake more rigorous simulation testing of their products before they are marketed.
Health care organizations and health care practitioners should not assume that technology will eliminate all medication errors. It takes a combination of improvements in technology along with constant and continuous vigilance by everyone involved in a patient’s care to reduce medication errors. The industry’s ultimate goal, after all, should be zero medication errors.
John P. Santell is the director of practitioner programs and services at the United States Pharmacopeia in Rockville, MD.
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