Better ways to catch medication errors

Accreditation Connection, October 19, 2003

Many medication errors could go unnoticed if you don’t have methods in place at your organization to catch them.

Such detection methods are important because medication errors represent the largest category of medically preventable deaths, according to an Institute of Medicine report cited in the 2002 VHA study, Monitoring adverse drug events: Finding the needles in the haystack. As many as 7,300 patients, 6,000 of whom are inpatients, die annually of medication errors, the Institute of Medicine report says.

Check out what VHA New England hospitals are developing in order to catch errors. The hospital network is grading different medication error detection methods and will help members tailor the procedures to their needs, says Arnold Mattis, RN, MSN, EdD, senior director of clinical and consulting services at VHA New England.

Methods vary by hospitals
VHA New England will receive advice from experts on the following four systems:
• Medical record trigger reviews
• Observational method
• Computer surveillance
• Practitioner intervention method

Each method that VHA New England grades has its benefits, Mattis says. The medical record trigger review trains people to look at a patient’s record to check for unanticipated events, any prescribed antidotes, or additional treatments.

Staff members investigate the events to determine whether an error occurred, and identify process failures rather than assign blame.

Almost 25 VHA member hospitals participated in a trigger review beginning in 2001, says Ken Smithson, MD, VHA, vice president of integration services.

Physicians, nurses, and graduate nursing students conducted the reviews, which cost about $1 per scan form. (See the sample trigger review tool to help you track adverse drug events in the PDF of this issue.)

“They can get into the business with relatively no investment,” Smithson says.

How the methods work
The VHA trigger review recommended that hospitals review 100 records per quarter to get an accurate understanding of what occurs.

Keeping error definitions consistent is also important, Smithson says. He points to one organization that, in order to maintain consistency, hired an outside contractor to conduct a review of its eight facilities.

The observational method is one of the more effective detection systems, Mattis says. An observer follows a nurse, records any medications administered, and checks the patient’s medical orders to see what should have been given. The organization then compiles statistics to track medication errors and identify their root causes.

Computer surveillance allows hospitals to compare the medication prescribed to medical records and specific laboratory values. For example, if a patient receives potassium supplements, the computer system will question whether he or she needs more medication with potassium in it, Mattis says.

The aid of technology
Computers can also allow physicians to order prescriptions, with safeguards preventing major errors. Brigham and Women’s Hospital in Boston saw an 80% reduction in overall medication errors, says David Bates, MD, of Brigham and Women’s Hospital in Boston (see how Brigham and Women’s cut its error rates below).

In the practitioner intervention method, the pharmacist checks the orders to see whether they are consistent with the patient’s needs, asks the physician why he or she prescribed that medication, and writes down any changes made to the original order. Pharmacies and hospitals can then design prevention programs based upon the prescribing errors detected.

Research shows that more than half of all medication errors are prescribing errors, Mattis says. Causes range from illegible handwriting, to similar-sounding drug names, to accidentally writing a medication order in someone else’s chart, he says.

“The more prescribing mistakes that are found and intercepted, the more likely it is for one to slip through, ultimately,” Mattis says.

Weighing the efforts
While some hospitals have used these active detection methods in the past—some organizations may have used the observational method for the last 15 years—many are not convinced that they are worth the cost and effort, Mattis says.

Most organizations use a self-reporting system, where staff members are responsible for reporting errors they commit or discover. Along with cost and time, the fear of reprimand or harm to one’s reputation may cause staff members not to report an error, Mattis says.
It is also possible for an exempt error to be made without anyone’s knowlwdge. “Many times the error-reporting process is tedious. People are busy, and if the error isn’t serious, it might not get reported,” says Mattis.

VHA New England’s board of directors asked the Medication Error Prevention Initiative (MEPI), a VHA New England task force, to begin reviewing error detection methods, Mattis says. The MEPI told the board of directors that there is no effective way to know how many errors occur with the self-reporting method in place, he says.

“This is an opportunity to look proactively for mistakes,” Mattis says. “Most people don’t yet see the full value of them.”

Create a system to meet your needs
Some organizations worry about finding the necessary manpower, training staff, and covering additional costs. While a hospital could hire an external firm to run the observation method, it is typically an employee effort, Mattis says.

The costs and time involved do not vary much from other existing procedures, Mattis says. Many methods are similar to infection surveillance programs that already exist at most hospitals, he says. A single error detection process will probably not meet an organization’s needs on its own, Mattis says. While the observational method has caught hundreds of errors more than other systems, observers only catch administration errors; prescribing errors go unnoticed.

The same holds true for the practitioner intervention system. While a pharmacist might catch an error before filling the order, the prescriber still provided the wrong information.

The trigger review would complement a computerized physician order entry system (CPOE) because hospitals could review an order and compare it to a patient’s record to find any adverse drug events, Smithson says. Community Hospital in Indianapolis participated in the VHA medical record review in anticipation of starting its own CPOE, he says.

“Each approach has its own limitations,” Mattis says. “We’re looking at them as a collection of approaches that could be used as a hybrid.”

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