Published in the October 2006 issue of Today’s Hospitalist
A report released this summer produced some disturbing statistics on the frequency of medication errors, some of which will hit home for hospitalists.
In the latest release in its “Quality Chasm” series, the Institute of Medicine (IOM) says that on average, U.S. patients experience some type of medication error every day they are hospitalized. That should be a sobering message for hospitalists, who, according to one of the report’s authors, need to take a bigger role on the front lines of detecting and preventing drug errors.
“Medication may be a technology with a great deal of value,” says J. Lyle Bootman, PhD, dean of the University of Arizona College of Pharmacy in Tucson, who co-chaired the IOM committee that wrote the report. But “it is one that we are not managing appropriately, safely and effectively.”
The report, “Preventing Medication Errors,” presents a sweeping view of system errors that beset every level of U.S. health care, from how government agencies function to the way that drug ordering systems and error monitoring systems are used.
To help American medicine get a handle on the problem, the report outlines a new national agenda to begin dealing with the epidemic of errors head-on. And according to Dr. Bootman, hospitalists have a major role to play in moving that agenda forward.
The frequency of errors
The IOM’s estimate that hospitalized patients experience an average of one medication error a day grabbed headlines after the report was released. But according to Dr. Bootman, all signs indicate that the problem is probably worse in the outpatient setting. Outside of hospitals, he explains, there is even less control over how patients select and use medicine, whether prescribed, over-the-counter, or herbal or dietary supplements.
Overall, the IOM committee estimated that there are “at least 1.5 million” preventable adverse drug events in the U.S. each year. And while the report says there were few reliable estimates for how much those events cost, it noted that one study put the annual price tag for drug errors in hospitals alone at $3.5 billion.
The keystone of the report, which was mandated by Congress, is a call for patients to take a more active role in monitoring their own medications. That advice turns on its head what the report called the “paternalistic” model of health care, a system that doesn’t actively engage patients in their own health care.
To boost patient resources, the report calls for a major overhaul of available medication information. It recommends that the FDA, the National Library of Medicine and other governmental agencies work together to standardize and improve medication information leaflets provided by pharmacies.
The report also calls for making information available over the Internet and developing a 24-hour national telephone helpline to give consumers access to drug information.
Trouble at transition points
But because there’s only so much that patients can do to prevent drug errors, particularly in the hospital setting, the report also charges physicians with getting more involved in informing patients about medications. That includes talking about errors when they occur.
The report goes to great pains to note just how vulnerable patients are to errors at transition points, particularly admission and discharge. Dr. Bootman says the report speaks directly to the ability of hospitalists to step up their efforts at patient education, particularly at discharge. After all, he asked, who is better suited to play a bigger role in identifying these types of transitional gaps “and fix them?
“We know that the number of patients who are discharged without the appropriate therapy is high,” he says. “Oftentimes on discharge, community doctors and pharmacies don’t have the appropriate information about medication use.”
To illustrate, Dr. Bootman cites the example of a patient discharged from a hospital with a limited supply of pain medicine. When the patient asked about refilling the medication, the hospitalist referred the person to the neurosurgeon. But it later turned out the neurosurgeon was out of town, leaving the patient with no access to a refill.
“It’s not the neurosurgeon’s fault or the hospitalist’s fault,” Dr. Bootman says. “It was the system’s fault, but it is still considered a medication error.”
Making a difference
Dr. Bootman says there are a number of areas where hospitalists can make a difference:
“¢ Pharmacy & therapeutics (P&T) leadership. For one, the IOM report recommends a much broader role for P&T committees in safeguarding patients against medication errors.
“P&T committees have a much more serious responsibility than just making decisions about whether to adopt a drug onto a formulary or not,” Dr. Bootman says. Instead, “P&T committees can play a preventive role to ensure the safe and effective use of drugs.”
It should be the responsibility of P&T committees, he adds, to anticipate possible mix-ups, educate hospital staff about similar sounding medicines, and set up extra-vigilant systems for ordering and dispensing such drugs.
“¢ High-tech approaches. The IOM report recommends that all health care organizations give clinicians electronic decision-support tools to help them guard against dosage errors and drug allergies.
The report strongly endorses e-prescribing, calling on all prescribers and pharmacies to use e-prescribing exclusively by 2010. “Handwriting is still a real problem,” says Dr. Bootman.
The committee also provides strong support for computerized physician-order entry systems, bar-coding identification techniques and the use of “smart” IV pumps. By using such technology, the report states, “it might be possible to reduce the medication error rate in hospitals on the order of 100-fold.”
The report also urges hospitals to capture information on medication safety, part of the IOM’s call for much broader research on safe medication use.
“¢ Talk to the team. Dr. Bootman points out another area where hospitalists can cut drug errors: include pharmacists on patient rounds.
“The errors that occur frequently in hospitals can occur because of the actions or inactions of pharmacists, physicians or nurses,” Dr. Bootman says. “But the biggest problem is that the three groups don’t talk to each other.”
Creating cross-disciplinary rounds, as well as investing in technology and increasing the scope and resources of P&T committees, all take money. Hospitalists need to make the case for those funds, Dr. Bootman says, with hospital executives.
“Administrators might say we can’t afford to have this happen,” he explains. “It’s the hospitalists who have to say that we require this type of service to be a part of our overall team.”
What kind of incentives does the IOM think are needed to spur hospitals “and physicians “toward wider use of error-reduction techniques? The report calls for accreditation and payment mechanisms to further adoption of those technologies and strategies, as well as for payers and purchasers to create explicit financial incentives.
The IOM’S “Preventing Medication Errors” report is available online or by calling 800-624-6242.
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
