Despite new technologies, drug-ordering errors persist
Errors in drug ordering, dosage, and monitoring that may have serious consequences for patients persist in hospitals even after the adoption of computerized medication systems, according to a recent study.
Several broad-based studies during the past 15 years have demonstrated that adverse drug events account for up to 41% of all hospital admissions and more than $2 billion annually in inpatient costs, according to the study. Many of these studies have also suggested that as much as a quarter of inpatient adverse drug events might be prevented through the use of computerized physician order entry (CPOE) and related computerized medication ordering and administrative systems.
Jonathan R. Nebecker, MS, MD, of the Veterans Affairs (VA) Salt Lake City Health Care System and colleagues conducted a daily review of the electronic medical records from a random sample of patients admitted to a VA hospital during a 20-week period in 2000 (Arch Intern Med 2005; 165:1,111-1,116). Because the VA Healthcare System is a leader in implementing multiple computerized interventions, including computerized physician order entry, bar code-controlled medication delivery, a complete electronic medical record, automated drug-drug interaction checking, and computerized allergy tracking and alerting, the authors suggest that a VA hospital offers an appropriate setting for testing the impact of computer systems on adverse drug events.
Pharmacists used standardized criteria to classify adverse drug events.
Among 937 hospital admissions, 483 clinically significant inpatient adverse drug events were identified. An adverse drug event was considered clinically significant when a change in the patient’s treatment plan was required. There were 52 adverse drug events per 100 admissions. One quarter of the hospitalizations had at least one adverse drug event. Nine percent of the adverse drug events resulted in serious harm; the other 91% were classified as moderate, requiring monitoring, interventions or discontinuation or adjustment of the dose of the problematic drug. The most common error types were failure to provide for expected adverse drug reactions — for example, prescribing potassium with diuretics to avoid a low potassium level (36%); failure to start or complete adequate monitoring for common adverse drug reactions (33%); and prescription of improper doses (33%) or inappropriate medications (7%).
The authors note that the computer system was successful in eliminating problems reading physicians’ orders (transcription), but did not resolve the other problems associated with administering medication, drug selection, dosage, and monitoring.
Overall, the study found high rates of clinically important adverse drug events even after adopting CPOE. Nebecker says "purchasers of CPOE systems should not rely on generic CPOE and bar code medication administration systems alone"
to dramatically reduce adverse drug event rates. Instead, health care organization should consider whether computerized medication systems offer decision support functions that address the most troublesome aspects of the medication administration process, he says. n
Patient transfer from ED can raise EMTALA risk
Question: Our ED transferred a patient to a sister facility for evaluation to be admitted to the detox unit. This was not a doctor-to-doctor transfer. The patient signed discharge paperwork from our ED, with the instructions that he go to detox. The other facility acknowledged receiving the fax of all his paperwork and said they would take him. An ED nurse called the other facility to give report to the one RN on duty there but could not reach her before the ambulance arrived to transport the patient.
The patient went ahead, and later our ED nurse got the other facility’s nurse on the phone after calling four times. The other facility’s nurse said the patient was already there, that he needed immediate treatment, and she accused our nurse of violating the Emergency Medical Treatment and Labor Act (EMTALA) for not giving a report before he arrived. It seems to me that there is no EMTALA violation since the patient was actually discharged and we just arranged transportation. But should I change any policy and procedure here?
Answer: You probably should change some policies and procedures, and you might need to have an inservice to refresh ED staff about EMTALA requirements, says Ashley Adams Feldman, JD, an attorney with The Phoenix Law Group of Feldman Brown in Scottsdale, AZ.
She works closely with health care providers now but previously was a prosecutor who brought charges against hospitals for EMTALA violations. She offers the unique — and hard-nosed — perspective of someone who frequently had to look at a situation and decide whether to pursue an EMTALA charge.
As to whether your ED staff violated EMTALA, Feldman says there is room for argument but as a prosecutor she probably would have considered you in violation. From the description of the incident, Feldman says it sounds like the patient may not have been stable enough for the type of transfer that happened. The statute requires that the facility making the transfer have contact with the other facility before the patient is actually moved. In this scenario, they never got in touch with anyone to discuss the patient’s condition, and successfully faxing the paperwork doesn’tcount for fulfilling that obligation, she says.
"I realize that the patient was discharged and that may have led the hospital to believe they didn’t have any more responsibility for that patient, but it sounds like there was something going to make the other facility think something was wrong. Either he was not stabilized or he was deteriorating in some way," Feldman says. "The law doesn’t have anything to say about discharging a patient and that making everything okay. Under the rule, you simply cannot transfer a patient who is not stabilized, whether that patient has been discharged or not."
If the physician at your facility determined the patient was stable, the physician at the other end apparently disagreed.
"It sounds like it may have been a wrongful discharge," she says. "You want to be overly cautious because the penalties associated with EMTALA are so severe. If you’re not sure whether a patient’s condition is deteriorating, it’s better to be safe than sorry."
Feldman acknowledges that the medical decisions regarding when a patient is stable can be difficult, and individual physicians will disagree. But nevertheless, she advises educating your ED staff about what EMTALA requires in terms of stabilization. The ED should have a protocol in place that requires contacting the other facility before the transfer, with clear documentation that receiving facility has been informed and has accepted the transfer.
The real problem in this scenario may be that the ED staff were led astray by the idea that the patient was discharged and that they were arranging transfer to the detox unit almost as a courtesy and nothing more.
"When you take on the responsibility of effecting that transfer, you are taking on the responsibility of meeting all the EMTALA obligations," Feldman says. "Even if the patient has been discharged, if you are going to in any way assist with that transfer you need to contact the other party, confirm the transfer, make sure they accept the transfer, and then send those records along with the patient."
With fines of $50,000 per incident possible, Feldman says risk managers should ensure their policies always require staff to be super strict with EMTALA requirements. "With fines like that, it’s foolish to play too close to the line," she says.
Errors in drug ordering, dosage, and monitoring that may have serious consequences for patients persist in hospitals even after the adoption of computerized medication systems, according to a recent study.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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