Error Reduction and Prevention
One of the most common medical errors is also the most easily preventable--medication error. A case study in a 640 bed New York hospital showed an average of 2.5 medication errors per day.
In a sampling of 36 hospitals and nursing homes, one out of every five dispensed doses of medication was:
A doctor hurriedly scribbling a prescription causing it to be misread is such a problem that some hospitals have sent doctors to a class to learn to write legibly.
If a prescription is misread, it could cause the ailment to advance and the patient to suffer from taking an unnecessary drug. The patient may have an ailment for which this wrong drug is contraindicated or the drug may duplicate another drug the patient is currently taking, causing a toxic reaction.
The patient may be allergic to a component of the medication. For example, the author has a friend who is allergic to thimerosal, a substance that is used to make flu vaccines. A vaccination for swine flu nearly killed him. He knew he could not have a flu vaccine ever again but he did not know that the eye drops his doctor gave him contained thimerosal, the same substance as in vaccine. Luckily, he only ended up with a rash on his eyeballs.
Adverse affects of a drug, some quite serious, may not be discovered until years after FDA approval. It is likely that the facility where the drug is commonly used will notice undocumented side effects before that declaration is made by the FDA.
Assumptions about medications or their administration have caused deaths. In the case of a 12 year old, a physician injected a drug into his spine instead of a vein, as was clearly indicated on the label, causing the patient's death.
A Washington pharmacist made the mistake of dispensed Levothyroxine in place of Lanoxin twice in a 15 month period. As a result of the second error, a patient skipped 24 doses of heart medication, ingesting a thyroid medication instead. The Washington pharmacy took steps post-incident to decrease what they termed the "rush" in part by scheduling pharmacists throughout the day. However, the board of pharmacy found the pharmacist negligent because it is the responsibility of the pharmacist to "deliver the drug that's been ordered and to check the prescription is the right drug, pulled and packaged in the right form." Further, the pharmacist did not have a detailed plan of action in place to prevent the second occurrence which meant he failed in his duty and as a result was disciplined by the board and placed on probationary status for 2 years. Of course, the pharmacist could easily face a civil law suit as well. Failure to adhere to a protocol or implement a policy where needed is considered negligent.
Common medicine errors at the pharmacy level are:
Many medications have similar spellings, labeling, and packaging which lead to medicine errors.
Inappropriate prescriptions are often waylaid by the pharmacist. The dosage or strength may not match the patient, leading to a toxic reaction. The directions may be incorrect which could cause the patient to take too little, too much or administer it improperly.
While in the process of writing this paragraph, the author received a call from a client. After hearing medication error was one of the most common medical errors, the client shared his story: His wife was having a prescription filled when the pharmacist asked the age of the patient. It was for their young daughter. The pharmacist explained the prescription was 10 times too strong for the child. The doctor who prescribed the medication had made a mistake in the dosage.
Pharmacies catch medication errors more easily if they have a policy in place that requires the pharmacist to do a "show and tell" for each medication, even if the patient is already familiar with the drug. Eighty-three percent of prescription errors are discovered in this simple step.
Similarly named medications should be double checked and separately stored in such a way as to prevent a pharmacist from mistakenly grabbing the wrong one. Codes and number references should be double checked. Storing and labeling should be done with care. The work area should be well organized and free from clutter.
Distractions are a key problem when handling medication. US Pharmacopeia recommends the following methods of preventing distractions.
Automatic dispensing systems reduce medicine error by selecting and labeling a vial, and counting, capping and sorting by name. The removal of extra manual tasks frees the pharmacists to focus on preventing medication errors.
If a doctor or pharmacist makes an error and a nurse has a role in dispensing or administering that medication, it is not uncommon for the nurse to take most of the heat. Circumstantially, the nurse is the one closest to the actual event--the gunman that pulled the trigger, so to speak.
Research has shown that fatigue, understaffing, inappropriate medication verification and overall job dissatisfaction profoundly affect the number of medical errors made by nurses in the clinical setting. About half of all errors a nurse makes are medication errors.
Thus, some states such as Massachusetts are looking at constructing laws limiting the amount of hours a nurse works. Hospitals are implementing limited shifts and improving working conditions for nurses, partly as a result of medical error statistics but they have succumbed to the demands of nurses' coalitions as well.
Routine practices help prevent medication errors. The following is one hospital's procedure:
First, the nurse reviews his/her patient's med sheets, to determine what medication is to be given and when. Then the nurse signs the bottom of the med sheet. Next the med sheet is removed from the book and taken directly to the computerized drug system, also known as the med cart. Some research suggests that computerized drug systems that are linked to pharmacies can reduce medication errors in hospitals by 86%. After the meds are pulled, the medication along with the med sheet is taken directly to the patient. Verification of the patient is then done by matching up the medical record number from the med sheet to the patient's ID band.
If the nurse suspects there may be a problem with the medication, the nurse must ask for further verification.
As one registered nurse put it, "Even if it is 3 o'clock in the morning and that doctor is furious at being woken up, too bad. It's the nurse's ___that is on the line. They must get clarification and understand what the reason is for the orders. For example, if there is an order to administer Digoxin, a cardiac medication, and the nurse sees the patient has a heart beat of less than 60 beats per minute, the nurse has the right to withhold the medication for clarification." Had Digoxin been administered the patient would suffer decreased cardiac output. Obviously, every player should know their medications.
As of July 20 2006, the FDA has this to say about what they are doing to curb the incidences of medicine errors. "We are partnering with the Institute on Safe Medication Practices to further refine our review of look-alike, sound-alike drug names, and will continue to evaluate our process before a drug is approved in which a proposed drug name along with its labels and labeling are evaluated for their potential to cause medication errors. We plan to issue guidance for industry on drug naming, labeling and packaging." Some consider this vague.