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Reducing Medication Errors

As the Baby Boomer generation closes in on retirement age, there will be an increased need for both health care and health care providers. According to Nancy Hellmich of USA Today, the number of medical visits rose 26% in 10 years, which is significantly higher than the 11% population growth during that same time period.  Spikes in doctor's visits can be attributed to longer life expectancies, access to life changing surgical procedures, depression, and diabetes. Of these visits, seven out of ten result in at least one medication being prescribed or renewed. With the growing amount of medications prescribed and dispensed, one would expect the health care industry's safety processes and procedures to have kept pace.  In fact, medication errors remain the greatest obstacle to good patient outcome and low institutional liability.   

The unfortunate truth is, medication errors are the most common of all medical errors.  A study in April 2009 of Intensive-Care Units in 29 countries found, “Medication errors were the second most frequent sentinel event, with a point prevalence of 10.5 medication errors per 100 patient-days” (Camire, Moyen, & Stelfox, 2009, p. 937).  Study after study confirms that medication errors are pervasive throughout hospitals, clinics, and doctor offices across the world.  The Institute of Medicine (IOM) estimates that medication errors cost the United States over $37 billion each year.  The IOM also believes an estimated 44,000 to 98,000 Americans die from medication errors each year, which is more than the 43,458 Americans who die annually in motor vehicles.

Recently, medication errors were brought to light when Dennis Quaid's newborn twins became part of the yearly estimated 1.5 million Americans who are victims of medication mistakes.  While in Cedars-Sinai hospital, the Quaid twins received 1,000 times the normal concentration of heparin, a blood thinner used to prevent clots.  Dr. Michael L. Langberg, Cedars-Sinai's chief medical officer, confirmed this was, “…a result of a preventable error” (Ornstein & Gorman, 2007, para. 3).  Quaid claims that Cedars-Sinai hospital personnel missed five crucial checks, leading to the twins’ heparin overdose.

There are many causes of medications errors.  In the case of the Quaid twins, a nurse picked up a vial containing 10,000 units per milliliter of heparin instead of the correct vial that contained a concentration of 10 units per milliliter.  In an academic medical center there may be 2,500 medications available, “each with a range of ‘allowable’ frequencies, doses, and routes of administration” (Wager, Lee, & Glaser, 2009, p. XXV).  This alone is a potential cause for errors requiring attention to label reading, dosage calculations, and understanding clinical math.  The most frequently reported errors result from incorrect infusion rates (40.1%), dosage omission (14.4%), wrong times (13.9%), and incorrect dosages (11.7%).

Each year, health care organizations are held liable for incidents of medication errors.  A hospital in Seattle experienced multiple errors involving incorrect dosages.  In one 18 month period, an infant died after a staff member administered the wrong medication; an eight-month old girl died after receiving 10 times the prescribed dose of calcium chloride; and a teenage boy died after receiving a lethal dose of a painkiller.   A medical malpractice law firm soon became involved when the media publicized that this single facility was responsible for these repeated fatal medication errors.

Reducing of medication errors can take many forms, from using proper injection techniques to employing technology.  For example, applying bar-code-enabled point of care (BPOC) can improve patient safety for administering medication.  Other strategies consider the stakeholders: physicians, nurses, pharmacists, unit directors, and the organization itself.  These strategies can include risk factor awareness, procedures for second checks, training, pharmacology education, and promoting a culture of safety.  Intensive-Care Units may consider physician work schedules as well as including pharmacist participation within their domain.  All of these approaches can help key stakeholders reduce medication errors and achieve drug safety goals.

With more medications coming to market and a growing population of patients receiving prescriptions, medication errors are certain to increase.  Applying old and new techniques along with improved technology can circumvent this trend.  Action must be quick and decisive.  Recently, the University of California at San Diego and Los Angeles noticed a surge in fatal medication errors by 10% in July 2010.  These discoveries are prompting additional steps to decrease patient risk including an in-depth evaluation of training programs.  Currently these programs teach proper injection techniques and clinical math for dosage calculations, but other topics still need to be addressed.  It is imperative that training programs focus on safety with an emphasis on basic procedural steps such as correct label reading. 

In conclusion, medication errors are the single most common of all medical errors.  They occur in hospitals, clinics, and doctor offices.  These persistent and ubiquitous errors present significant obstacles to good patient outcome and low institutional liability.  The health care industry is developing different ways to correct what is certain to become a growing problem if left unchecked.  Introducing new delivery methods and intensive safety training are just a few ways of avoiding medication errors.  The Patient Protection and Affordable Care Act passed in 2009 expands health care to millions more Americans.  This expansion of coverage, coupled with a maturing Baby Boom generation requiring more health care indicates these are unprecedented times and health care providers must be ready for them.


References

Bakalar, N. (2008, January 22). In the Lab:  Simple Math Errors Can Imperil Patients. The New York Times.

Camire, E., Moyen, E., & Stelfox, H. T. (2009, April 28). Medication errors in critical care: risk factors, prevention and disclosure. Canadian Medical Association Journal, 180(9), 936-941.

Hellmich, N. (2008, August 7). Aging population making more visits to the doctor’s. USA Today.

Kadam, A. M., Ganachari, M. S., Bhise, S. B., & Gurunath, S. (2009, September 6). Medication Errors Related to Antibiotics in Medical Intensive Care Unit in a Tertiary Care Teaching Hospital in South India:  A Prospective Study. Journal of Pharmacy Research 2009, 2(8), 1245-1248.

Medication errors significant. (2009, July). Australian Nursing Journal, 17(1), 9-9.

Ornstein, C., & Gorman, A. (2007, November 21). Possible medical mix-up for twins. Los Angeles Times.

O’Callaghan, T. (2010, June 2). Study: fatal education mistakes surge in July. Time Healthland.

Slutkin, A. G. (2010, June 30). Improper Injection Medical Malpractive. Maryland Medical Malpractive Lawyer Blog.

Wager, K. A., Lee, F. W., & Glaser, J. P. (2009). Health Care Information Systems:  A Practical Approach for Health Care Management (2nd ed.). San Francisco, CA: Jossey-Bass.