Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology
David M. Benjamin, PhD, FCP
From the Department of Pharmacology & Experimental Therapeutics, Tufts University School of Medicine, Boston , Massachusetts
Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the new politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to "prevention" and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is "an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done." What should be done is generally known as "the five rights": the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly).
This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. "System errors" are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the "safety net" that failed. Examples of reengineering the system to make it more "error proof" are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care.
Last, reducing medication errors is an ongoing process of quality improvement. Faulty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.
Reference:
The journal of clinical pharmacology http://jcp.sagepub.com/cgi/content/short/43/7/768 March 1, 2010 8:33 PM
SELF REFLECTION
In this article they are recommending that the sloppy handwritten prescription should be replaced with a CPOE or writing all drug orders in just plain English, rather than using the Latin words and shorthand abbreviations. Doctors are famous for sloppy handwritten prescriptions which lead to thousands of medication errors each year. Illegible handwriting and transcription errors are responsible for as much as 61 percent of medication errors in hospitals. A simple mistake such as putting the decimal point in the wrong place can have serious consequences because a patient's dosage could be 10 times the recommended amount.
For me, it is a great idea since not all Filipinos can understand Latin words and shorthand abbreviations. Some are having a hard time understanding it because the words are either difficult to read due to sloppy handwriting or because it is new to them. Perhaps prescriptions are written this way because it carries on a tradition that organizes information in a standard way that pharmacist and other health care professionals will understand. But there are so many ways for it to go wrong that the case could be made to require plain language instead of abbreviated Latin on medication orders.
According to them, using computer system upon typing "ii po qid", the prescription reads "2 by mouth 4 times daily." I'm amazed not only by how helpful a computerized prescription-entry system is but how unnecessary my struggles in my class were. The advantages to a computer-assisted prescription system go well beyond making the writing legible.
Still, while technology is not a perfect solution for the problem of medication errors, I do believe that technology, if appropriately and aggressively used, holds great promise for researching, identifying, reporting, and reducing medication errors. In particular, I believe that electronic prescribing, with proper systems design, implementation, and maintenance, can contribute significantly to the prevention of medication errors.
