Healthy Skepticism Library item: 749

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Publication type: news

Hospitals Step Up Efforts To Avoid Medication Errors
The Wall Street Journal 2005 Jan 12

Full text:

It’s a simple enough concept: Hospitals should find out what medications a patient is taking when he or she is admitted.

Yet too many hospitals don’t have a medication-checking protocol, opening the door to potential disaster, like a diabetic returning to a hospital recovery room without a resumption of insulin after surgery or a heart patient being discharged with a drug that duplicates one he’s already taking.

Studies show that nearly half of medication errors happen because of mistakes made during admission or discharge. By the end of this year, the Joint Commission on Accreditation of Healthcare Organizations, the leading accreditation group for hospitals, will require all hospitals to adopt procedures that include collecting a complete medication list, verifying it, and ensuring it is passed on to the next provider, whether inside or outside the hospital.

So hospitals are turning to “medication reconciliation,” a system of formal procedures to identify the most accurate list of a patient’s medications, and compare them at every step of the way with drug orders a doctor makes during admission, surgery, transfer or discharge.

Medication-reconciliation programs are one of the half-dozen “best practices” that hospitals are undertaking as part of the Institute for Healthcare Improvement’s “100,000 Lives” campaign, which aims to enlist 1,600 hospitals across the country to adopt changes in care that have been proven to prevent deaths due to medical errors. IHI has signed on more than 450 hospitals since announcing the program late last year. Many medication snafus, such as wrong drugs or dosages, are intercepted by hospital staff, or don’t lead to serious harm; many mistakes, however, end up causing serious injury, and even death.

Most people assume hospitals know everything about a patient’s medical records and “can’t believe that a hospital wouldn’t know your medications,” says Roger Resar, a Mayo Health System safety expert. Dr. Resar led the development of medication-reconciliation programs a few years ago at one of the Wisconsin hospitals in the Mayo system. The programs helped cut medication errors by 70% and reduced “adverse drug events” — that is, medication-related injuries — by more than 15%.

Dr. Resar, who is working with IHI on its program to spread medication-reconciliation programs around the country, says that while nurses and hospital pharmacists warned of the problem for years, many doctors have underestimated the importance of medication lists, assuming the information would be sorted out eventually — or if there were complications, the hospital could deal with them.

With a growing number of patients being treated for one or more chronic diseases, the dangers have become more acute, notes Gina Rogers, director of the medication-reconciliation program at the Massachusetts Coalition for the Prevention of Medical Errors. “Many patients are seeing multiple doctors, and are taking many drugs that they may be ordering from different places, so it’s often hard to get a complete and accurate list,” says Ms. Rogers. In her program, 50 hospitals in the state last year began using a standardized form listing all of a patient’s medications; the form is attached to a patient’s medical record and is checked before and after every hospital procedure, and when a patient is discharged.

Hospitals are also assigning medication-checking responsibility to specific staffers, such as pharmacists, who track down doctors to ask about any discrepancy in the records.

Discrepancies in medication records are alarmingly common. For instance, one study found as many as 42% of medication orders for pediatric cancer patients needed to be changed following a reconciliation review.

One problem is that patients and family members fail to provide complete medication information, so it’s important to compile a list of prescription drugs and their dosages and bring it to the hospital at admission time, especially before a scheduled surgery. Patients typically are taken off their medications to avoid complications from anesthesia during surgery, and doctors may fail, for example, to restart antidepressants or they may take an epileptic patient off seizure medication and not resume it after surgery.

Such mistakes are particularly dangerous for diabetics who depend on insulin; researchers at the University of Missouri found that 33% of the errors that caused death within 48 hours involved insulin therapy and administration, such as failure to resume insulin therapy after a procedure or surgery. The American Association of Clinical Endocrinologists just announced that it will provide hospitals with insulin safety recommendations, including the use of computerized order-entry systems that check medication orders against a patient’s medical record.

But Peter Pronovost, a patient safety expert at Johns Hopkins University School of Medicine, says that computer systems can’t help patients if the correct drugs and dosages aren’t entered in the first place. “Someone needs to decide what drugs the patient is really on,” Dr. Pronovost says, noting that his studies showed that in 70% of surgical patients there was some discrepancy in their medication history.

ICU patients are at especially high risk because they are often on many medications. Johns Hopkins started a medication-reconciliation program that required ICU nurses to spend about 20 minutes during admission and 20 minutes upon discharge taking medication histories and checking for any discrepancies. In a study of that program, doctors had to change orders for 31 of 33 patients as a result of an error. Dr. Pronovost says such errors have now been eliminated.

One of the biggest dangers is prescribing a generic medication to a patient that may duplicate a brand-name drug he or she is already taking. Ms. Rogers of the Massachusetts error-prevention group notes that a heart patient sent home with a prescription for the generic drug digoxin may inadvertently double the dose by resuming taking a brand-name prescription such as Lanoxin. An overdose of the drug can be highly toxic. Mayo’s Dr. Resar adds that for that reason, medication-reconciliation checklists are especially important at discharge: While you’re in the hospital, staffers may intercept drug errors, he says, “but once you go home there is no such guardian angel.”