New IOM report underscores ongoing threat of med errors
Report: Hospitalized patients experience average of one error per day
The Institute of Medicine (IOM), which shook the health care profession to its core with the 1999 publication To Err Is Human, has targeted medication errors once again with a new report, Preventing Medication Errors.
The report notes that medication errors are among the most common medical errors, harming at least 1.5 million people every year; the extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year; and this estimate does not take into account lost wages and productivity or additional health care costs.
Among the report's recommendations is that health care organizations create plans to implement electronic prescribing by 2008 and actually implement it by 2010.
The IOM also urges all pharmacies to be able to receive electronic prescriptions by 2010, and suggests ways to improve the naming, labeling, and packaging of drugs to reduce confusion and prevent errors.
The report also covers a number of areas already familiar to quality managers, such as establishing and maintaining strong partnerships between health care providers and patients. It recommends specific steps that physicians, nurses, pharmacists, and other health professionals should take to ensure that their patients are fully informed about their drug regimens and to minimize opportunities for mistakes to occur. Health care organizations, the report says, also should make it a standard procedure to inform patients about clinically significant medication errors made in their care, whether the mistakes led to harm or not. Currently, it says, health care providers typically do not inform the patient or the patient's guardians about errors unless injury or death results.
Also included are actions patients should take, such as requesting that their providers give them a printed record of the drugs they have been prescribed. Patients should maintain an up-to-date list of all medications they use — including over-the-counter products and dietary supplements — and share it with all their health care providers.
In addition to emphasizing the potential of new computerized systems for prescribing drugs and other applications of information technology to reduce the number of drug-related mistakes, the report says that all health care provider groups should actively monitor their progress in improving medication safety. Monitoring efforts might include computer systems that detect medication-related problems and periodic audits of prescriptions filled in community pharmacies.
Errors significant, preventable
Edward Westrick, MD, PhD, vice president of medical management at University of Massachusetts Memorial Health Care in Worcester and a member of the IOM's Committee on Identifying and Preventing Medication Errors, says the report re-emphasizes a continuing truth in health care. "I think despite all of the confusion and the variations in how performance is measured, going all the way back to the IOM report in 1999, what really shone through was there is a significant problem," he asserts. "No matter how you count it, we have a significant problem with medication errors in this country."
He notes, for example, that some people may argue over the report's assertion that there is one error per patient per day in the U.S., "but we believe it's accurate. And the truth is, whether it is 0.8 or 1.3, it's too many."
Another sobering point, he continues, is how many of these errors are actually preventable. "If we really put in the things we need, like EMR [electronic medical records], medication administration records, POE [physician order entry] with physician support and took it very seriously — and redesigned care processes around the capabilities these allow — we could reduce the error rate 100-fold," Westrick asserts. "Whether that really adds up to $100 million annually you could argue, but the take-home message is the system is not doing what we want it to do."
"I would not necessarily put a number on it, but if you redesign systems and take advantage, you will get a substantially reduced error rate," says Justin Graham, MD, director of medical informatics for San Francisco-based Lumetra, the Medicare quality improvement organization (QIO) for California.
You cannot think of a computer system as a stand-alone entity, divorced from the human beings on your staff, he continues. "An ATM, for example, is more than a piece of computer programming — it has totally transformed and redesigned how things work in a bank. In the health care setting, I think of it as being similarly transformative, though there has not been that much adoption yet."
Graham's vision is that there will be more efficiency surrounding hospital medication delivery. "In terms of bar-coding and maintaining the five 'rights' of medication, it will change the work flow; bar-coding will have a big impact on nursing," he observes. "But it can't be imposed; nurses will have to come to terms with how it will impact work flow. If you do not take that into consideration and work through the cultural issues, nurses will not do the predictable things you want to make things safer; they may, instead, do workarounds."
So, for example, the patient will have the bar-code on his or her wrist, but the nurse may feel the recommended process would take too much time and just take it off the wrist and put it on the wall, so he or she does not have to wake the patient up. "If the nurse feels it's a little too much trouble, all of a sudden that safety parameter gets cut out," Graham suggests. "So it's not just a technology problem — you have to have a holistic approach. The stated goal must be preventing errors, and you have to change the culture so it includes 100% use of bar-codes, even if it means things will be a little slower and you have to wake the patient up to bar-code their wrist."
"Bar-coding continues to be a significant method for improving medication safety; it helps make sure you have the right patient and the right drug at the delivery point," says Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. "Bar-coding is most effective when the codes are on the individual doses of medication and on the patient's wristband and the wand is light and easy for the nurse to carry around."
IT systems not perfect
Despite the promise of technology, Westrick is quick to point out there can be pitfalls. "They can be extraordinarily expensive and can be disappointing in their impact," he says. "The proper message should have been that, although they are necessary to get that 100-fold improvement in the error rate, careful implementation of the technology is absolutely critical. Things can go wrong, and we need to respond; we need to have an implementation plan."
"I couldn't agree more," says Graham. "We've seen a lot of high-profile implementations gone wrong, and sometimes do more harm than help."
While CPOE (computerized physician order entry) fixes a lot of things that traditionally go wrong, such as poor handwriting, "It introduces new errors no human ever would do, like, for example, ordering eardrops for the spinal canal," Graham offers. "It the computer mapping is wrong, the wrong drug can get delivered. Computers do not use logic, and we have to be aware of these things."
How can human beings minimize these machine errors? "In addition to having a plan, you have to measure what you do," Graham recommends. "You need to ask, 'What are my problems? How do I measure them?' Then institute the technology and keep measuring to see if you are solving those problems — and you have to have a plan to make sure you are using the technology to maximum effect."
In other words, he says, your responsibility does not end when you go live. "You are now obligated to take maximal advantage — keep all your order sets up to date, as well as your content, make sure the docs use the system appropriately and do not bypass steps, that your formularies are matching, and so forth."
"IT really can be a very useful tool," adds Foster. "But it is critically important, based on the literature, that you involve your medical and nursing staff — and of course the pharmacists who will be using that system — in the design and implementation of health care delivery for your organization."
In the end, she says, the system must be timely and effective for practitioners. "It is helpful if people can readily see that the alerts they get back have been well thought through and are consistent with the best medical science," notes Foster. "If you have too many alerts coming back, clinicians may start dismissing them. What we want to eliminate are things that can really lead to harm."
But there is no doubt that IT can make a world of difference. "For folks who do quality improvement work for a living, they know how labor-intensive it is to move data around," says Westrick. "Right now, most places use the typical ordering, transcribe, dispense cascade — the doc writes the order, the unit clerk or nurse takes it off the paper record, enters it onto other pieces of paper, and before that they make sure there is not an error in the order or the prescription. If there is, they have to contact the prescriber to discuss it, then fax or mail the order to the pharmacy so they can go on to the dispensing step.
"Imagine a system where clinical information on the patient is available in a timely fashion," he continues. "The order goes directly to the medication administration system, logic checks and identifies errors in prescribing, and the correction is made. At the same time, the order can go to the pharmacy for them to take dispensing action."
Combination of systems improves safety
It is the combination of a number of these systems (IT and human) that will really improve safety, says Foster. While bar-coding ensures you have the right patient and the right drug, "Different kinds of CPOE systems help make sure the drug that is ordered is consistent with the existing medication recommendations and dosage standards, and medication reconciliation makes sure you know what the patient is taking when they enter and that the patient knows what they should continue to be on when they leave the hospital," she notes. "Together, they can really create a medication safety system."
The IOM report agrees. "One of the major recommendations is to keep an up-to-date and accurate list of medications and what the patient is using," says Westrick, but then offers this warning: "It doesn't say this in the report, but I think it's not just about that; it's about having a complete and accurate meds list. Reconciliation is designed to accomplish that, but I've seen places where people get so caught up in the process, they don't accomplish it."
Foster agrees. "As I listen to people in the field, the commitment to effect these changes is significant, but actually accomplishing it is much more difficult and complicated than people anticipated," she notes. "We continue to learn how to do it effectively; and people are trying to learn from each other."
Westrick goes on to note that the Joint Commission calls for medication reconciliation at major transitions in care. "In the report, we go a little further and say that a complete and accurate meds list ought to follow the patient wherever they go," says Westrick, agreeing with Foster that when a patient leaves the hospital "they ought to have a complete and accurate meds list."
This should happen even if the facility does not have an EMR, says Westrick. "It could be on paper," he notes. "The patient can have their list and bring it with them."
Westrick echoes the report's call for greater responsibility on the part of the patient. "They really need to be the keeper of information," he explains.
"This requires more responsibility on their part than the health care professionals have been asking, but this is also the responsibility of the health care professional. Providers should educate the patient, tell them what they want them to take, and why and how, and what to do when they experience unanticipated adverse events. I know it's a burden to provide that kind of counseling, but we consider it a requirement," Westrick says.
Leadership makes the difference
There are several keys to successful initiatives to reduce errors, say the experts. When it comes to IT, Graham notes, one of the most important elements is "strong leadership that understands the importance of these issues we've discussed — that thinks about how to drive more efficiency in the work force and drive errors out; that is willing to spend up-front money to get long-term gains."
Looking at the long term is critical, says Westrick. "The report has an ROI [return on investment] section that shows one system developed and operated over 10 years cost around $12 million and achieved net operating savings of almost $10 million," he notes.
Strong buy-in from clinicians also is critical, says Graham. "They have to think of it as a clinical project and not just an IT project," he explains. "They have to own it, be on top of it, and when there is a problem, they have to take ownership. Then, they have to follow through with momentum and measurement and appropriate training."
Such training, he concedes, can be "really expensive," but cannot be given short shrift. "That applies not only before the system goes live but during and after," he says, "Because later on people can forget what they have learned, or are ready to do more advanced stuff and therefore need to learn more."
You should establish clear parameters for success, he continues. "Reward physicians and staff for being leaders and really adopting the system," he recommends. "Also, if you set up a project, plan to have one with a lot of quick 'wins'; you need to show success quickly or you will lose buy-in."
The quality manager's role will vary from facility to facility, he says, but it should not be undervalued. "In some cases, they may be the chief quality officer and sit at the leadership table; other times they are buried very deep in the organization," he notes. "But if quality isn't the reason for implementing these systems, you probably are not doing it for the right reason. It is totally appropriate — if not essential — for folks involved in quality improvement to be at the table."
Finally, says Westrick, in order for medication error reduction programs to be effective, they must be interdisciplinary. "Pharmacists, physicians, nurses, patients, family members, and maybe other health care professionals should be involved," he advises.
But it's not enough to bring together a group of different people, he stresses. "We talk about competencies required of team members, and you must understand the responsibility for understanding and maintaining the competencies of the team," he says. "That's part of one of the overarching recommendations — it's not only about technology, but also about the culture of safety improvement. The team must monitor their own performance, identify where there are opportunities for improvement, and redesign the processes."
This process, he says "absolutely underscores the importance of the role of the quality manager."
For more information, contact:
Edward Westrick, MD, PhD, Vice President of Medical Management, University of Massachusetts Memorial Health Care, Biotech One, 365 Plantation Street, Worcester, MA 01605. Phone: (508) 334-1000.
Jenna Fischer, Senior Project Manager, Lumestra, San Francisco, CA. Phone: (415) 677-2071. E-mail: [email protected].
Nancy Foster, Vice President for Quality and Patient Safety Policy, American Hospital Association, 325 Seventh Street, N.W., Washington, DC. Phone: (202) 638-1100.
The Institute of Medicine (IOM), which shook the health care profession to its core with the 1999 publication To Err Is Human, has targeted medication errors once again with a new report, Preventing Medication Errors.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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