Published in the March 2005 issue of Today’s Hospitalist
Doctors’ poor handwriting may be an old joke, but the latest report from the United States Pharmacopeia (USP) shows that scrawl is no laughing matter. More than 6,000 times in 2003, in fact, medication errors were due, at least in part, to illegible or unclear handwriting.
That represented 3 percent of the total number of medication errors reported voluntarily that year to the USP. And just as importantly, the percentage of medication errors attributable to handwriting problems hasn’t improved at all during the past five years “which is as long as the USP has been collecting and analyzing data on medication errors as part of its Medmarx project.
Physicians’ use of abbreviations in prescriptions caused another 7,400 medication errors in 2003. Such “dangerous” abbreviations, which were misinterpreted by pharmacists, nurses and patients, accounted for 4 percent of medication errors in that year, a number that has increased over the last five years.
These trends are important, explains Diane Cousins, RPh, vice president of the USP’s Center for the Advancement of Patient Safety, because physicians often want to see evidence of a problem before they are willing to consider making a change in how they practice.
“What this five-year report shows is that these problems are occurring,” she adds, “and that they are occurring at a frequency that we feel should require our attention. There are now data to support Joint Commission patient safety goals, such as eliminating the use of dangerous abbreviations.”
These trends have been compiled and analyzed in the “Medmarx 5th Anniversary Data Report,” which was released in December. The USP has been collecting data on medication errors since 1998, and its most recent report includes analysis of more than 235,000 medication errors. About 10 percent of all health care institutions nationwide “typically those caring for inpatients “voluntarily and anonymously report errors to the Medmarx database.
There were 24 patient deaths associated with a medication error reported to the USP in 2003. The drugs most likely to cause harm or death when errors occurred and failed to be intercepted are opioid analgesics, anticoagulants and types of insulin.
Still, data from 2003 showed signs of improvement. Ms. Cousins notes that more near misses are being intercepted by pharmacists and nurses before they reach patients. In 2003, for example, only 1.51 percent of errors ended up harming or killing a patient. That number was down from between 2.5 percent and 3 percent between 1999 and 2001.
Just as importantly, the percentage of errors that were made but caught and fixed before they reached patients has jumped dramatically over the past five years. In 1999, for example, 23 percent of the total errors reported that year were intercepted. In 2003, by comparison, that number had risen to 38 percent.
“What we are hearing from hospitals is that they are making a more conscientious effort to intercept errors “in particular pharmacy intercepting physician errors,” Ms. Cousins says. “This relates to increased vigilance, an increased commitment to try to find and stop errors earlier in the system.”
It’s important to know about those kinds of interceptions, she says, because they are viewed as “precursors to more harmful events.”
By focusing on near misses, she adds, health care organizations can design and reinforce existing safety nets “or create new ones.
She points to computerized physician order entry (CPOE) as a prime example. While the technology can help reduce errors, data from the USP shows that CPOE may need its own set of safety nets, because incomplete patient names, drug doses and laboratory test results are all making their way into systems and are contributing to drug errors. In 2003, in fact, prescribing problems related to CPOE were the fourth leading cause of medication errors.
Another interesting statistic: Over the years, the percentage of errors that can be tracked back to the prescription-writing process has jumped from 11 percent to 23 percent. At the same time, the percentage of errors originating in the administering phase has decreased from 40 percent to 31 percent.
Ms. Cousins cautions against reading too much into these data, noting that they may reflect a change in the definition of medication errors. Until recently, she explains, medication errors were typically viewed as any deviation from a prescriber’s order, because it was generally presumed that orders were correct.
“Now we know errors are made during prescribing too,” Ms. Cousins explains, “and there is an increased vigilance and commitment in catching errors in the prescribing phase.”
Ms. Cousins says that the USP is heartened by the fact that so many more health care organizations have decided that reporting medication errors outweighs any potential cost. Hospitals and other organizations have often worried about the increased malpractice exposure or bad publicity of reporting problems.
Despite those concerns, the number of facilities reporting medication errors to the USP over the last five years has skyrocketed from 54 to 580. Perhaps even more encouragingly, the number of reports coming from those organizations has increased at a much greater pace.
“This is a cultural change,” Ms. Cousins says. “People are more willing to share their stories.”
And while she acknowledges that medication errors are still underreported, she says that the USP is “learning a lot from the records we are able to pull together each year for this study. What we are learning is that the more we talk about it, the more we can do about it. Knowledge is power.”
While she has seen attitudes change about the value of reporting medication errors, Ms. Cousins is quick to acknowledge that more work remains to be done. The five-year data, for example, show little change in how hospitals react to the news that an error occurred, even one that was caught and fixed before it had a chance to reach and harm a patient.
If hospitals were truly working to create a culture of safety in their institutions, Ms. Cousins says, they would follow up after identifying a medication error by making changes in various processes and systems. Data, however, show that this type of change is slow in coming.
Only about half of the time, in fact, do staff who made the error hear about the problem, and that type of notification “not any kind of broader system change “is the most common action taken after an error is found. “We are top heavy with this ‘Don’t do it again’ type of reaction,” Ms. Cousins says.
Changes in notification
Nonetheless, she says, there were more reports of hospitals instituting “systems changes” in 2003 than in previous years.
For instance, patients and caregivers were informed of an error more often (5.5 percent) in 2003 than in the preceding years (4 percent). And in nearly 1,000 instances, computer software was changed as a result of an error.
The USP’s report also points to some fallout from the ongoing nursing shortage. Between 10 percent and 13 percent of medication errors each year can be attributed to factors Ms. Cousins calls proxy measures for the staffing shortage. They include everything from insufficient, inexperienced, temporary and floating staff to cross coverage and increased workloads. In more than 40 percent of the cases reported to Medmarx, “distractions” were blamed the most for contributing to the error.
“Everyone was saying they thought staffing shortages might be a threat to patient safety,” Ms. Cousins says. “I think what you are seeing here is the proof that it is in fact a threat.”
Finally, the most common types of medication errors have remained steady over the last five years, with improper dose and omission both being reported about a quarter of the time. Prescribing errors occur another fifth of the time.
Interestingly, however, Ms. Cousins says the data show that while errors of omission happen most frequently, the types of errors that are most likely to end up causing patient harm are mistakes related to “wrong administration technique.” An example is crushing a sustained release tablet or pushing a medication rapidly that is supposed to be given over a minimum of an hour.
“It’s a very low-volume error,” she explains, “but it is often disproportionately associated with harm.”
Deborah Gesensway is a freelance writer in Toronto, Canadam who writes about U.S. health care.
The five drugs most commonly involved in reported errors in 2003
- Potassium chloride