Patient Safety Alert

Institute seeks elimination of hand-written prescriptions

ISMP says prescriptions should be electronic by 2003

Prescription medication errors claim up to 7,000 American lives annually and cost upward of $77 billion a year, according to a report released late last year by the Institute of Medicine.¹ The average indemnity payment for claims related to medication errors between 1985 and 1992 was nearly $100,000 — not counting out-of-court settlements.

And because hand-written prescriptions are a primary source of medical errors, the Institute of Safe Medication Practices (ISMP) has called for their elimination by 2003.

The medical community has made efforts to curb the odds of misinterpreting handwritten prescriptions. However, such prescriptions remain one of the last and perhaps most important paper transactions in our computerized society, according to a report by the ISMP. And not only do most clinicians continue to write prescriptions by hand; they also rely on memory for drug names, dosages, strengths, and directions. The ISMP calls this system archaic, and in order to save lives and avoid costly lawsuits, is calling for a voluntary change to automating the prescription function.

Ahead of their time

Some physicians jumped on the electronic prescription bandwagon early as headaches related to insurance companies and potential errors pushed them into the computer age.

It’s been about a year since both Lisa Abrams, MD, internist at Lake Forest Hospital in Deerfield, IL, and Azar A. Korbey, MD, family practitioner in Salem, NH, began using electronics to prescribe medicine.

"Sometimes doctors’ handwriting is horrendous," says Abrams, a former pharmacist. She says her handwriting is legible because "I would be embarrassed if a pharmacist couldn’t read my writing."

Insurers reject prescriptions

But when she was a pharmacist, Abrams says there were times when she would have to call the physician at 10 p.m. if she couldn’t read a prescription. "And doctors can be mean. They will really yell at a pharmacist for questioning their prescription," she says.

Korbey, who is left-handed, admits his handwriting leaves something to be desired. "In the past, we would get tons and tons and tons of phone calls back from pharmacists saying we can’t read this script, your handwriting is lousy. I would say, I know that,’" Korbey said.

But neither physician began using an electronic system specifically for the purpose of eliminating handwritten errors. Rather, both entered the electronic era because insurance companies were constantly questioning or failing to pay for prescriptions.

"I wanted some ease and some way of just being confident I’m not going to get call-backs [from insurance companies] on my prescriptions," says Abrams. "It was driving me crazy. They would call me back, and I’m like, why doesn’t the insurance company become the doctor? What sense is it that I’m a doctor if the insurance company is going to reject half the prescriptions I’m writing?"

Insurers were rejecting prescriptions in favor of generic, cheaper, or alternative brands, which may or may not be as effective. Without a patient history, companies are unaware of antibiotics a patient has unsuccessfully tried.

Korbey was experiencing similar problems in New England. He says managed care companies have so many different formularies that it had become impossible to keep track of them all.

"I’ve become lazy; I don’t even want to write a prescription anymore," Abrams says. "[Electronic prescribing] is very convenient, and it’s hard to make a mistake. There are prompts on the system if you do make a mistake."

Technology is out there, so use it

Recently, according to the ISMP, a number of newly launched Internet companies have introduced on-line pharmacy fulfillment services that include a prescribing feature linking practitioners to dispensing facilities across the country.

Unfortunately, ISMP estimates that less than 5% of U.S. physicians use the new technology.

Several recent studies in hospitals have shown that physicians who use an order entry program have fewer errors. For example, one study found a 55% reduction in errors with potential for harm; the program greatly reduced the need for transcription, and it minimized misinterpretations caused by illegibility. In a study of intensive care patients, a computerized system helped physicians reduce the incidence of allergic drug reactions and excessive drug dosages by more than 75%. The average time patients spent in the unit dropped from 4.9 days to 2.7, cutting costs by 25%, according to the ISMP.

To date, most research on the prevalence of medication errors and adverse drug events has focused on error rates in acute care settings. One noteworthy study found that adverse drug events occurred at a rate of 6.5 per 100 admissions. A study of two prestigious teaching hospitals determined that two of every 100 patients admitted experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,685 for each affected patient. Annually, that figure is $2.8 million for a 700-bed hospital. Generalized across the nation, the figure is $2 billion. These figures exclude medication errors that lead to hospitalizations and outpatient events.

The ISMP recommends taking action before legislators or task forces insist that electronic prescribing be utilized as fully as possible.

Who’s at fault for the errors?

Errors can be made at any point during the process of prescribing and filling a prescription, according to the ISMP.

In many instances, when pharmacists cannot read a physician’s handwriting, they make an educated guess, Korbey says. Guesses likely are based on a physician’s instructions and what the patient says.

"The potential exists for errors," says Ruth Noland, PharmD, of Aventis Pharmaceutical, Kansas City, MO. "That’s why it is really important to talk to the patient. Some have a better understanding of their illnesses and medications than others."

Research shows that injuries from medication errors are not the fault of any individual health care professional, but rather the failure of a complex health care system that includes patients who do not follow prescription instructions.

Other problems not under the control of physicians involve those related to the naming, labeling, and/or packaging of drugs or to inefficient distribution practices.

"It’s scary how close many of the names are," Abrams says. "There are so many drugs out there, I think pharmaceutical companies are just running out of names."

Korbey says one of his patients was given the wrong medication because of a "sound alike" mistake. "They were two entirely different medications. One was for anxiety and one for high blood pressure," he said.

And that error is the only one he knows about. "But even one error is too many," he said.

Additionally, the volume of prescriptions pharmacists face is so high that the workload becomes overwhelming, experts say.

When Noland worked for a retail pharmacy, she said it was not uncommon to fill up to 300 prescriptions a day. Korbey says in any given day he writes up to 40 prescriptions.

According to the National Wholesale Druggists’ Association, nearly 2.5 billion prescriptions were dispensed in 1998. The National Association of Chain Drug Stores estimates that number will reach 4 billion by 2005.

Reference

1. Institute of Medicine. LT Kohn, JM Corrigan, MS Donaldson, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

For more information, contact:

Lisa Abrams, MD, internist, Lake Forest Hospital, Deerfield, IL. Telephone: (847)535-8333.

Azar A. Korbey, MD, family practitioner, Salem, NH. Telephone: (603) 893-7905.

Ruth Noland, PharmD, Aventis Pharmaceutical, Kansas City, MO. Telephone: (816) 966-3640.

To view the Institute of Safe Medication Practices’ full report, visit its Web site at www.ismp.org.

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How to encourage staff to report medical errors

Work on systems, not individuals

How can a hospital encourage staff to report errors? Cheryl Warnick, RN, MN, CPHQ, director of risk management at Sacred Heart Medical Center in Spokane, WA, says, "We hope to drive up reporting by removing any kind of punitive approach to the use of incident reports, so the staff feels free to report. When people see we are working on systems, not individuals, they will see there’s no assignment of blame."

As vice president of medical affairs at Sacred Heart, a tertiary care center, Tom Miller, MD, leads the root-cause analysis (RCA) endeavor. "The Joint Commission came out two years ago or so with its sentinel event policy, mandating root-cause analyses of sentinel events and near misses. We call them RBTs for really bad things.’ We found that it was most productive in running an RCA if we sat down with hospital employees and physicians and told them we were not out to hang them. Instead, we were looking at the system’s problem as a breakdown in the hand-off from one system to another. Maybe in the past, those people felt that they were at risk for discipline."

Miller’s team tells them up front, at the start of the RCA, that the perpetrators are not at risk for discipline, and the word is getting out that people involved in a sentinel event or RBT are not in trouble. When the employees figure out they are not going to be disciplined, they become interested in solving the problem and coming up with ways to solve sentinel events or RBTs. They are no longer afraid to say things that in the past may have gotten them punished.

Ryland P. (Skip) Davis, CEO of Providence Services, Eastern Washington as well as Sacred Heart, says, "The number of incident reports filed in a hospital are about a third the number that really occur. That’s because if you think you’re going to be disciplined and your report will be held against you, if you can bury it, you probably will. We say, Forget the punitive side of the equation. Instead, let’s talk about how we can make patient care safer, how we can simplify work processes, and how we can work as a team to improve the environment." He and Miller tell staff, "If you find something that’s disrupting the opportunity to make patient care safe, feel free to give suggestions. Report problems so we can identify areas of concern. The information won’t be held against you."

Miller says that, last fall, Sacred Heart began using Excalibur Patient Safety Net medical errors analysis software, marketed by Safety-Centered Solutions (SCS) in Tampa, FL. The facility hired a clinical analyst to input data, then set up a safe care leadership team that included a few staff-level hospital employees who deal directly with patient care, a couple of vice presidents, and some people from middle management. "During one of our brainstorming meetings, we realized we had to come up with a reporting system that is nonpunitive and an incident report or quality improvement report that doesn’t require identification of the employee," Miller recalls.

Rather than reinventing the wheel, Sacred Heart is using a variation of a form that was developed at St. Luke’s-Shawnee Mission Health System in Kansas City.¹ "There’s a lot of reporting that’s supposed to go on in a hospital," explains Miller. Sacred Heart has about 3,800 employees. "One advantage of SCS is that the reports will be kept in one place, in a computer, where they will be used to identify trends and get positive results."

Sacred Heart’s clinical analyst, Sharon Skinner, RN, observes that when employees are told for years to fill out forms and file reports, and nothing happens when they do, they decide, "Why bother? It’s just a waste of time and nothing’s going to change." Skinner talked with service line directors and devised new reporting forms that are easier and faster to use than the old ones. When an employee sees a problem, he or she checks it off on the form and sends the form to Skinner. "It’s critical to get voluntary reporting, and people are going to report things voluntarily only if they feel some good is going to come of it," says Miller.

Skinner explains that Sacred Heart started with a baseline of retrospective information from existing incident reports on patient falls, medication errors, and nosocomial infections because those events cost most. "Our new reporting form is a checklist for tracking and trending everything from service delays to complications of invasive procedures such as hemorrhage hematoma. Those complications should be on incident reports, but they usually aren’t." Asterisks on the form remind staff that reports should accompany those.

"We are a huge facility," says Skinner. "Nurse managers are trained on Excalibur so they can access information at their desks. We’re hoping also to make the information available to people who do direct patient care so they can be aware of and address the trends. It doesn’t do administration much good if they don’t get information from everywhere." Skinner used to be director of quality assurance at a Montana hospital, so she’s sensitive to nurses’ hesitancy to add to their work load.

"Each unit will have specific items it will want to track and trend based on where staff have seen problems in the past," she says. "Typically, incident reports are filled out, addressed at the time, then filed away. They are not looked at on a continuum. With the new Joint Commission regulations, we need to address problems in a nonpunitive way. And that makes sense because 80% of events are process problems."

Culture change is essential

Skinner says it takes a while to change the climate of a hospital, but it’s a positive step to put staff and administration on the same page. "Our administration now looks at patient care first and cost savings second. We’re all after the same outcomes. Both want to increase reporting and not emphasize reprimands." She says supervisors have historically used incident reports to identify clinicians, rather than look at what caused a problem. Here, the emphasis is on the process.

"We’re now looking at these things proactively rather than retrospectively," she says. "I did an investigation recently on patient falls. We looked at the correlation among patient age, length of stay, and admitting diagnosis. What was asked was, When did the fall occur?’ Some occurred on admit date, and many of those fallen patients had not been identified as being at high risk to fall, even though they had had a fall at home over the past six months. It’s good to know that type of information so in the future, we can flag high risk to fall’ at admission. That can help with preventing injuries."

Warnick says Sacred Heart is in the process of getting the SCS system up and running. "We’ve formed a safe care leadership team to look at trends and patterns coming out of the Excalibur database, but we don’t yet have an action plan." Warnick says she hopes the system will point her in the right direction by showing trends and patterns in medication errors and patient falls — "any adverse event that would rear its ugly head. Our concentration is now on the prevention of patient falls and medication errors."

She says Sacred Heart’s errors have been very low for the past 15 years. "But we’re underreported, like everyone else in the country." The purpose of the program is to increase reporting so administrators and staff can know what the facility’s trends and patterns are, then fix the system so they can drive down the error rate. Once the facility is able to identify systems problems, the staff can fix them and create a safer care environment.

Providence Services, Eastern Washington negotiated its contract with SCS to have a system license for all the facilities in its regional delivery network of five hospitals, one of which is 623-bed Sacred Heart. The others are small, rural, community-based facilities. Excalibur is now being loaded into two of these, Holy Family Hospital and Deer Park Hospital.

For more information, contact:

Ryland P. Davis, CEO; Tom Miller, MD, Vice President of Medical Affairs, Providence Services, Eastern Washington; Sacred Heart Medical Center, Spokane, WA. Telephone: (509) 474-3131.

Cheryl Warnick, RN, MN, CPHQ, director, risk management; Sharon Skinner, RN, clinical analyst, Sacred Heart Medical Center, Spokane, WA. Telephone: (509) 474-5126.

Reference

1. DeJong D, Brookins LH, Odgers L. Multidisciplinary redesign of a medication error reporting system. Hospital Pharmacy 1998; 33:1372-1377.

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