Reduction in Medication Errors in Hospitals

Reduction in Medication Errors in Hospitals

Rajeev B. Patel

Spring 2004

INTRODUCTION

According to the Institute of Medicine’s 1999 Report, To Err is Human, “medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.[1] In fact, between 44,000 and 98,000 people die each year as a result of all types of medical errors.[2] Errors due to medical mistreatment, insufficient information, and inefficient processes are the fifth leading cause of death in the United States.[3] Of the reported deaths due to medical errors each year, 7,000 deaths can be attributed to medication errors.[4] Patients who survive medication errors often have to pick up some fraction of the cost of higher utilization associated with remedying their ailment.

A critical method for providers of care to reduce adverse events associated with medication errors is to focus on ways of improving the systems of delivering care. In order to sustain and improve upon established levels of care, it is critical that health care facilities evaluate options to integrate information systems as a mechanism to eliminate preventable medication errors. Aside from the obvious cost of life, there are widespread implications to errors that lead to injury, including costs associated with increased hospitalization, increased medication, lost wages, and decreased patient satisfaction. According to Laurence Goldberg, a consultant and pharmacist who spend considerable time analyzing medication errors “an adverse drug event will, on average, lengthen a patient’s stay in the hospital by 2.2 days at a cost of $4,684”.[5] It is estimated that such injuries result in 2.4 million extra hospital days and $9.3 billion in extra charges for longer stays and additional care per year.[6] Central to the problem our society faces in coping with medical errors is that the majority of the errors are preventable. Part of the overall problem is the delivery and administration of medications which can be controlled and improved upon to reduce adverse effects of potential errors. The objective of this chapter is to provide you with an understanding of how medication errors impact quality of care, patient satisfaction, and overall outcomes while providing methods to reconcile mediation errors.

Problems arise from the decentralized and fragmented nature of the supply chain (see bottom of page)*[1] where there currently is a lack of continuity with staffing at both the ward and pharmacy level of the medication supply. The end result is a poor chain of supply which creates delays, poor communication, and ultimately leads to the incorrect administration of medication. Additionally, in situation when patients see multiple providers for various treatments in different settings, patients can also be more susceptible to potential medication errors due to lack of continuity in maintaining their records. Interventions involving the use of automated information systems which are capable of tracking and collecting relative information have consequently been identified as a tool to reduce medication errors. Examples include computer physician order entry (CPOE) systems, automated dispensing technologies, bar coding technology, and electronic medical records for each patient.

AUTOMATED INFORMATION SYSTEM APPLICATIONS

Computerized Physician Order Entry (CPOE) system: CPOEs are desk top electronic devices physicians are equipped with to enter medication prescriptions. The orders are usually integrated with patient information and automatically checked for errors or adverse interactions. This not only eliminates the guess work in deciphering handwritten dosage and medications but also provides an additional layer of verification for appropriate medication and dosage. As physicians enter prescription orders into an automated prescribing system, errors are detected at the time medications are ordered. The orders are then integrated with patient information and automatically checked for potential errors, complications, or adverse effects.

Bar Coding Technology: Bar codes can effectively address medication errors on two levels. First, the use of bar codes on medication packaging can ensure appropriate use of medications. Second, bar codes can be used as unique patient identifiers at the time medication is administered. This serves to address and eliminates medication errors associated with incorrect dosage, incorrect patient, and timing or frequency. Before administering medication, the nurse would scan the bar code on the patient with the bar code of the medication to ensure the right patient is being given the right drug at the right time. Bar codes not only reduce medication errors, but they streamline workflow and improve patient safety.[7]

Med Administration Check[8] is an example of a bar coding product that has successfully been implemented in many hospitals in the U.S. Of the 2% of hospitals using similar technologies, an average of 84 to 264 potential errors are prevented each week while an average of 50 calls to the pharmacy per day has been eliminated.[9]

Electronic Medical Records (EMR): EMRs essentially are electronic charts for each patient. Computer programs can then be designed to alert clinicians about possible adverse drug interactions, dosage problems or other prescription errors. The EMR has many capabilities, including prescription and test ordering. This electronic based tool, along with CPOEs eliminates medication errors due to transcribing and administration.

Automated Dispensing Technologies: Automated Dispensing machines are interactive systems that perform functions related to the storage, packaging, dispensing, or distribution or medications, and that collect, control, and maintain all transaction information.[10] For example, MDG Medical, Inc. has manufactured a secure closed-loop computerized system which effectively manages the deployment of medicine to the patient from time of prescription through the administration stage. ServeRx® is a secure closed-loop system which has proven to drastically reduce medication errors, improve management of medicine and enhance patient safety.[11]

MEDICATION ERRORS TARGETED

The delivery of medication typically involves 5 distinct steps which include the following: prescribing, transcription, dispensing, administration, and monitoring.[12] Table 1 illustrates the results of a study which indicate that most of the errors occur at prescribing or administration stage.

Table 1: Medication Errors[13]

Medication Errors	Types of Errors
Prescribing 39%	Wrong Dose 28%	Drug-drug Interaction 3%
Transcription 12%	Wrong Choice 9%	Wrong route 2%
Dispensing 11%	Wrong Drug 9%	Extra Dose 1%
Administration 38%	Known Allergy 8%	Failure to act on a test 1%
Monitoring 1%	Missed Dose 7%	Equipment Failure 1%
	Wrong Time 7%	Inadequate monitoring 1%
	Wrong Frequency 6%	Preparation error 1%
	Wrong Technique 6%	Other causes 11%

While other causes associated with medication errors include unavailability of patient information, illegibility of physician handwriting, poor communication between nurses, pharmacy, physicians, and technicians, the majority of cases involve errors in drug selection and delivery.[14] According to Table 1, if 28% of patients are given the wrong dose, layers of verification clearly need to be implemented and enforced throughout the process to reduce and control for errors associated with human interpretation. It is imperative that facilities maintain databases which contain most frequent drug-to-drug interactions based on medications recently cleared by the Federal Drug Administration. If systems are in place to periodically account for drug-to-drug interaction updates, errors can effectively be reduced by 3%.[15] A periodic update of drug-to-drug interactions account for allergic cross-reactions which can be most harmful when not addressed. Electronic updates can be found and downloaded at the following web site:

http://www.docs.com/support/Files/Drug%20Interaction/default.asp

The following link provides critical installation documentation which allows you to continually update your records:

http://www.docs.com/support/Files/Drug%20Interaction/DrugInteractions4052002.pdf

You are required to have SOAPware Version 4.71 or later which you can learn more about through the links listed above. This application is available to the public and is a valuable and practice way to learn about and avoid future medication errors related to drug-to-drug interactions. A disciplined approach to implement a continuous update protocol will reduce medication errors in your facility.

APPLICATION: Automated Medicine Dispensing Technology – An Integrated Approach

Figure 1 illustrates how the various information systems can improve each step the delivery process. The focus of this discussion will address how a ward based closed-loop automated dispensing unit effectively addresses errors associated with each step in the medication delivery process.

Figure 1: Role of Automation in Medication Delivery Process[16]

Prescribing

- Physician order entry

- Computerized design support

↓

Transcription

- Electronic Order Transcription

↓

Dispensing

- Bar Coding

- Automated Dispensing Devices

↓

Administration → Medication Administration Record

- Bar Coding - Computerized medication record (EMR)

- Automated Dispensing Devices

↓

Monitoring

- Computerized monitoring of adverse drug events

The primary caregivers responsible for orders, transcribing, dispensing, administering, and documenting the delivery of medication to patients include physicians, nurses, and pharmacists. The critical success factors to improving patient safety and better medical outcomes involve eliminating preventable errors at each stage of the medication delivery process accounting for the actions of each stakeholder through an automated process with layers of verification. While the reduction of medical errors ultimately seeks to eradicate preventable injuries, a secondary objective addresses the significant savings providers, patients, and payers can reap as a result of improved processes.

To address the growing need to standardize the delivery of medicine to control for the unacceptable level of risk attributed to patients, closed-loop (access not available via internet of computer networks outside hospital) medicine management applications effectively controls the entire medication process from prescription to delivery to monitoring. The primary objective of this system is to promote better medicine management by reducing medication errors which subsequently enhances patient care and outcomes, while generating valuable cost savings.

This system is a fully integrated application that consolidates the delivery of medicine. This application addresses all aspects of medicine administration at the service or patient floor level. Reducing dispensing errors by maintaining adequate inventory levels and accurately identifies recipient or patient receiving prescribed medicine through barcode technology, CPOE, and electronic medical records which serves to eliminate errors related to patient identification.

Included is a computer hardware and software, an automated medication cabinet that is placed in the nursing station, and a cart that is used to dispense medication to patients.[17] Briefly, when using the system, a doctor electronically enters a patient’s prescriptions into the CPOE system. The computer sends the prescriptions to a nursing station computer, which verifies the orders based on the patients condition, past prescription history, and drug to drug interactions. At the dispensing stage, the computer opens an automated drawer in a medication cabinet which stores each drug individually. A patient specific drawer simultaneously opens in the cart which prompts the nurse to seamlessly transfer the medication from the cabinet to the drawer upon which both drawers close. Nurses then take the cart to patient rooms where patient barcodes (located on patient’s wrist) are scanned matching the medications with the patient. Subsequently, the drawer matching the patient to the medication opens on the cart administering the medication. The nurse completes her rounds and returns the cart to the station. Table 2 documents the process in more detail.

Table 2: Systems workflow in detail

The system workflow consists of the following steps beginning with the physician and concluding with the nurse returning the medicine cart to the docking station:

Step	User	Technology	Process
1	Physician	CPOE	Using a hand-help computerized physician order entry (CPOE), physician uses touch screen to access patient information (height, weight, diagnosis, current medicines and allergies, graphical display of vital signs) and places order.
2	Pharmacist	Electronic Medical Record (EMR)	Information is transferred to pharmacist who reviews order, makes changes if necessary and authorizes transaction. Pharmacist authorization is mandatory according to HIPAA, IRB, State Pharmacy Boards, and other national regulatory bodies.
3	Nurse	Stationary Apparatus, Cart	On the patient floor, the nurse reviews information for the administration of medications at the central system. The nurse accesses patient delivery schedule and alerts delivery staff.
4	Nurse	Stationary Apparatus, Cart	On the computerized touch screen, the order list for each patient is displayed. The nurse confirms the order and medicine cabinet doors open one at a time (minimizes possibility of human error). Nurse retrieves medicine then places medicine in patient specific cart (mobile apparatus used to deliver meds at point of care) drawer. Each patient specific drawer is programmed with patient specific information including dosage, time, and route. The nurse double checks the order.
5	Nurse, Patient	Cart, Bar-Code technology, EMR	Once all medicines are placed in the cart, nurse is ready for rounds. Nurse delivers medicine to each patient. Nurse scans patient barcode ID bracelet which then opens patient compartment on cart. Nurse verifies information is logged into cart.
6	Nurse	Cart	Nurse returns cart to machine. Information regarding distribution of medicines is transferred to main system and logged. Patient drawers used during rounds open and are cleared. Cart is now ready for next round of distribution, thus closing the loop.

In this application, physicians utilize the CPOE which runs on a portable handheld computer. The CPOE assists each physician analyzes patient records while prescribing appropriate medications. Linked to a central database, physicians are alerted to adverse drug-to-drug interactions as well as inappropriate dosages which prompt the physician to reselect correct medication and dosage amounts. CPOE systems improve safety in several ways. First, all orders standardized to include a dose, route,and frequency. Second, and perhaps most critical, orders are legible (transcribed) and canbe identified by the pharmacist in all instances. Third, information can be accessed by the pharmacist at any time during the process. Lastly, all orders canbe checked for a number of problems including allergies, druginteractions, overly high doses, drug-laboratory problems (givinga patient a drug when they have a known biochemical factor thatpredisposes them to risk), and whether the dose is appropriatefor the patient's condition.[18] Decision support in the prescribing stage critically reduces the potential for medication errors attributed to physician orders and in many cases reduces the need for order transcription. Additionally, an electronic record maintains the integrity of the order improving patient safety and expected outcomes.

At the dispensing stage, prescriptions are authorized directly at the workstation in a readable format while patient records are accessible by the nurse. Additionally, pharmacists are able to review orders at their leisure at their own workstation to provide an additional layer of verification. This information also allows pharmacists to adequately manage inventory of medications stored within the unit itself.

The administration of medications is automated alerting nurses of pending tasks. Nurses are equipped with access cards which allow entry into a single drawer on the cabinet and a single drawer on the cart. The cabinet electronically monitors prescriptions and dosage time and route providing an additional layer of verification. At the bedside, the patient barcode is scanned and the proper cart drawer is opened. Bar coding ensures the correct preparation and dispensing of medications. While bar code scanning is a critical element of the machine, the technology as a stand alone, can significantly improve medication errors by ensuring the correct preparation and dispensing of medications. The use of barcode scanning allows simultaneous access to the patient’s medical records, information regarding the medication, information regarding correct dosage and frequency, and creates a seemingly flawless path towards the correct administration of medications. Bar coding not only improves workflow, but reduces medication errors and dramatically improves patient safety.[19] Moreover, patient barcode allows nurses to internally verify the 5 rights: medication, dose, time, route, patient. An automated bar coding system integrated into the process reduces the need of paper records which effectively eliminates opportunity for human error in delivery of medication.[20] It provides information needed to continually improve the safety and quality of the hospital’s medication management process. Moreover, bar coding receives substantial support from nurses by relieving their apprehension about making errors, reducing their administrative burden, and promoting accurate documentation and charge capture improving efficiency.[21]

Lastly, prescriptions and medication administration are recorded only once, mostly at the point of care as part of the routine workflow. This ensures completeness of documentation for patient safety and enhances clinical decision making with credible support. A comprehensive documentation process with one point of entry allows information to be collected, analyzed and monitored appropriately by physicians, nurses, and pharmacists. While the closed-loop system provides a tool to reduce medication errors, it is not a solution in and of itself. Proper data documentation and collection allows subsequent medication errors to be analyzed and addressed more efficiently.

COST IMPLICATIONS

In addition to controlling risk factors that may harm a patient, inpatient facilities will realize tremendous cost savings through this application. Moreover, errors due to patient mix-ups will be eliminated by the application of barcode technology, which reduces medication errors by 65-86% by serving as the gatekeeper for final delivery of medicine to patient[22]. Errors associated with incorrect dosages and dispensing of incorrect medicines with similar names will virtually be eliminated. The application of this process also increases physician and nurse productivity which help to address issues related to nursing shortages. In fact, overall nursing time for medication workflow with this application has decreased by 6.1 hours per 24-hour shift.[23] Nonetheless, the expected benefits of this system will help to increase staff productivity, create cost savings for the facility, and most importantly, increases patient care and satisfaction.

QUALITY IMPLICATIONS

Significant emphasis has been placed on the value of standard reporting systems by accrediting organizations such as the Joint Commission for Accreditation of Health Care Organizations (JCAHO). The need for quality improvement is more prevalent now than it has ever been. Along with a heightened need to reduce preventable errors, costs must be controlled to adapt to declining reimbursements. Operational and clinical synergies are opportunities to enhance patient experience and is proven to effectively reduce both cost and medication errors. Current initiatives include implementing operational processes that have been successful in other industries, such as Six Sigma, as a way to create operational efficiencies. Six Sigma, which provides a formal analysis of the source of error, establishes a high standard for acceptable quality is now widely accepted in healthcare as a powerful quality improvement tool. The Six Sigma standard is a management tool that concentrates on measuring outcomes and error rates identifying opportunities for improvement. If implemented successfully, errors will be limited to 3.4 per 1 million opportunities. Alternative process improvement methods which have been successful in healthcare include ISO 9000 and the Baldrige Criteria.

There are several barriers which may prevent the successful integration of information systems in health care environments around the world. Certainly, a significant investment, both financially and time, must be made to learn how systems discussed in this chapter can be successfully integrated. Users must be willing to learn and change the way they practice to meet success. Moreover, providers of care must have the infrastructure to apply new technologies or information systems. Otherwise, they simply will not work.

CONCLUSION

Successful integration of information systems depends on the widespread support and acceptance among physicians, nurses, and pharmacists. One of the primary challenges to successfully reduce medication errors is to gain acceptance. Allowing each entity to guide the design and support of such systems is critical to the overall success. Information systems are simply a tool that allows providers to address the glaring need to reduce medication errors. Cultural workflow attributes equally impacts the successful integration of information systems. Access to capital, which poses a significant problem to low volume community facilities, is certainly an obstacle towards the integration of information systems. However, there are low cost options including process re-engineering which can address larger issue contributing to medication errors, such as standard communication procedures. While the closed-loop design addresses all medication process steps, resource allocation and consumption can be a limiting factor. The shortage of nurses and pharmacists combined with clinician’s limited time must be considered and evaluated in the design and implementation of the system. Time savings, reduction in workload, inventory management, and lower medical costs are byproducts of an improved system that improves patient safety by dramatically reducing medication errors.

Patient safety in all aspects is the cornerstone and expected future state of such initiatives and requires the continued collaboration of all participants. The critical success factors which include improvements to each step in the medication delivery process, also includes acceptance by users, as well as strong linkages to organizational strategic plans.[24] Creating the perception that the anticipated future state involves the intended implementation of each critical success factor in succession will ultimately penetrate and resolve problems at hand sustaining an environment commensurate with strategic objectives.

For Further Research

Institute of Medicine: http://www.iom.edu
Medical Errors: http://www.mederrors.com
MDG Medical, Inc.: http://www.mdgmedical.com
Institute for Safe Medication Practices: http://www.ismp.org
To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America. 2000. Institute of Medicine.
Crossing the Quality Chasm: A New Health System for the 21^st Century. Committee on Quality of Health Care in America. 2001. Institute of Medicine.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- http://www.jcaho.org
The Institute for Healthcare Improvement – http://www.ihi.org
National Foundation for Patient Safety – http://www.npsf.org
American Medical Association – http://www.ama-assn.org

ENDNOTES

*1 A set of approaches utilized to efficiently integrate suppliers and clients (comprised of stores, retailers, wholesalers, warehouses, and manufacturers) so merchandise is produced and distributed at the right quantities, to the right locations, and at the right time, in order to minimize system wide costs while satisfying service level requests. http://www.stanford.edu/~jlmayer