Medical Mistakes: Where Do We Go from Here?

Consumers and those in the medical professions were stunned when the Institute of Medicine (IOM) released its startling report To Err Is Human: Building a Safer Health System. In the opening paragraphs of this groundbreaking report on patient safety, the IOM estimated that 44,000-98,000 hospital patients every year died as a result of medical errors.

That was in 1999. In 2006, the IOM issued another study, called Preventing Medication Errors, reporting that medication errors harm at least 1.5 million people every year.

Medication errors encompass all mistakes involving prescription drugs, over-the-counter products, vitamins, minerals, or herbal supplements. Errors are common at every stage, says the IOM, from prescription and administration of a drug to monitoring the patient's response. "On average, there is at least one medication error per hospital patient per day, although error rates vary widely across facilities," notes The National Academies, of which the IOM is a part.

According to Preventing Medication Errors, approximately 400,000 preventable drug-related injuries occur each year in hospitals; another 800,000 occur in long-term care settings; and roughly 530,000 occur just among Medicare recipients in outpatient clinics.

Confusion Occurs throughout Drug Processing
Medical errors often result from a series of minor mistakes. All systems have errors, but in the field of medicine, events such as miscommunication between staff members or between patients and their health care providers can have serious or even fatal consequences.

Approximately 56% of errors occur during prescribing, 34% during administration, 6% during transcription and 4% during dispensing processes (Bates D, Cullen D, Laird N et. al.). A significant portion of ordering and dispensing errors are caught before ever reaching the patient, however, most administration errors are not caught because they occur at the point of patient care. Technologies such as bar-coding and dual verification checks can help reduce administration and transcription errors.

One important part of this problem relates to drug names. Most drugs have three names - the chemical, generic, and brand names - and each of these categories is subject to different rules and regulations. According to the US Food and Drug Administration (FDA), confusion caused by similar drug names accounts for up to 25% of all errors reported to the Medication Error Reporting Program, which is operated cooperatively by US Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). In addition, labeling and packaging issues were cited as the cause of 33% of administration and dispensing errors, including 30% of total adverse drug-related fatalities.

Health Care Organizations Respond
Most medications are not intentionally misused; the errors result from information that is not clearly explained or not clearly understood.

Computerized systems for prescribing drugs and other applications of information technology show promise for reducing the number of drug-related mistakes. Electronic prescribing is safer because it eliminates problems with handwriting legibility, notes the FDA, and can also alert prescribers to possible drug interactions, allergies, and other problems.

The Medical College of Wisconsin and Froedtert & Community Health (a partnership of Froedtert Hospital and Community Memorial Hospital of Menomonee Falls) are in the process of implementing a state-of-the-art Clinical Information System that simplifies and standardizes the human side of processes, and improves communication between health care providers and their patients. It was created with Epic Systems of Madison, Wisconsin, considered a leader in information technology.

The system will integrate medical records, clinic scheduling, and information storage and retrieval; electronically link hospitals and clinics; and improve communications and information-sharing among members of the patient care team. When the system is fully implemented, each patient will have one Electronic Medical Record (EMR) that will keep track of all treatments, medications and appointments.

"This project demonstrates our commitment to quality care, partnerships, technological leadership, customer service and patient safety and does it within a secure system that safeguards each patient's confidentiality," said Rick Gillis, MD, Medical Director of Clinical Informatics at Froedtert & the Medical College.

In addition to creating a single EMR that contains all a patient's medical data, the new system utilizes ISMP's Guidelines for Safe Electronic Communication of Medication Orders. The guidelines use standardized drug naming procedures that make it easier for health care providers to order the right drugs and easier for patients to understand the names, dosages, and other instructions.

Michael Sura, Pharm D, Froedtert Hospital Director of Clinical Informatics, notes that these conventions have been in place in the hospital's Inpatient Pharmacy since May of 2004. "As we built the medication records into the Epic system we incorporated these nomenclature recommendations in to the records," he says.

"Medication names are consistent across the enterprise. Brand names are always capitalized; generic names are always lower case; and we use 'tall man' lettering when necessary, typically in medication names where look-alike or sound-alike issues occur." 'Tall man' lettering makes use of both upper- and lower-case letters to distinguish between commonly confused drugs, for instance EPINEPHrine and ePHEDdrine or hydrOXYzine and hydrALAZINE.

Rather than using abbreviations such as D/C, which could mean either "discharge" or "discontinue," words are spelled out. Drug names are also spelled completely: in the past, MTX (methotrexate) has been misunderstood as mitoxantrone; MSO4 (morphine sulfate) has been misinterpreted as magnesium sulfate).

Labels will read "use for three days" rather than "x3d."

These standards clarify drug names and dosages for health care providers and consumers, who can now read labels and instructions in natural language.

Ask
Despite the best efforts of the medical community and individual health care practitioners to develop perfect systems, mistakes will always happen. Fortunately there are steps that patients can take to help prevent errors.

Keep a written list of all your medicines and treatments and give a copy of it to each of your health care providers. Keep the list up to date when medications or doses change. On the list, include:

• Names of prescription medicines, including any samples your doctor may have given you
• Names of over-the-counter (OTC) medicines, or medicines you can buy without a prescription (such as antacids, laxatives, or pain, fever, and cough/cold medicines)
• Names of dietary supplements, including vitamins and herbs
• Any other treatments
• Any allergies or other problems you may have had with a medicine
• Anything that could have an effect on your use of medicine, such as pregnancy, breast feeding, trouble swallowing, trouble remembering, or cost

Many people will have an easier time at the doctor's office if they bring a friend or relative to help keep track of any discussions. This is especially important for those who have problems hearing, seeing, reading, or other issues that might limit their comprehension. If you don't have someone with you, ask for written information and advice about all your medications. If the information seems unclear or incomplete; make sure you ask for an explanation right away, before you take any of the medicines.

Ask your doctor, nurse, pharmacist, or other health care provider to give you written information about your medications. Do not be embarrassed if you have a hard time understanding, or say that you understand their explanations if you really don't. The more medications you take, the more difficult it is to keep track of them. Most health care providers will welcome your questions.

Much of this information is available on the papers attached to your medications when you pick them up, but sometimes it is complicated. Pharmacists are a great resource for any medication questions; if there is anything you don't understand, ask immediately.

Research
Pharmacies, libraries, bookstores, pharmaceutical companies and the Internet can provide you with more than enough information to research your medications and other treatments. Make sure the information is up to date and applies to your specific situation. If, like many of us, you use the Internet as your main source of health and medical information, be aware that very few laws regulate online information: almost anyone can write almost anything and put it on the Internet.

Stay away from websites that give opinions or advice without facts, especially sites that are trying to sell you products that sound "too good to be true." These sites are not trustworthy. They prey on consumer's hopes for an easy path to good health.

If you do look up drug information on the Internet, use only reputable sites such as Medline Plus, provided by the National Library of Medicine and the National Institutes of Health. It is thorough and written in consumer-friendly language. You can look up drugs by either their generic or brand names. You can also look up over-the-counter drugs (OTCs), herbs, and supplements.

The Department of Health and Human Services' healthfinder Health Library includes many medication topics, including a drug database, and even a drug interaction checker where you can select each one of the drugs, vitamins, and herbals you take and get results telling you if they will interfere with each other.

In addition, the FDA provides a great deal of data about drug safety in general.

The issue of medication safety is complex and will be difficult to resolve. A great deal of effort is being made by health and medical organizations, and the use of new, innovative systems technology will have an enormous impact on productivity, efficiency and patient safety.

Despite these efforts, mistakes will still occur. Together with our health care providers, each of us must become healthcare advocates for ourselves and for each other.

Eileen Early, BA, BSN, RN
HealthLink Editor

This article includes information from the US Food and Drug Administration, the National Academies, the Institute for Safe Medication Practices, and Bates D, Cullen D, Laird N et al., Incidence of adverse drug events and potential adverse drug events. (JAMA 1995;274:29-34).

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.