Taking on medication errors

One per patient per day.  That is the number of medication errors of all kinds that occur in hospitals, according to a 2007 report by the prestigious Institute of Medicine.  These include errors of omission and commission, wrong time, wrong dose, wrong route and wrong patient events.  The overwhelming majority are inconsequential; nonetheless, researchers have estimated that upwards of 380,000 to 450,000 episodes of medication-associated harm occur each year.

Opportunities to create - or prevent - errors occur at every step in the process from the time the physician orders a medication, through communication to the Pharmacy, dispensing, and administration at the bedside.  Some medications are more dangerous than others - those that are more toxic, more complicated to dose, those that look like or sound like other, dissimilar medications, and those prescribed for the most vulnerable patients (including children) deserve special attention.

Among our most serious challenges is addressing the risk of error when patients transition from one environment from another - home to hospital, or hospital to rehab, for example.  There is even a risk when the patient moves from one unit to another in the same hospital - ICU to floor, for example.

Yesterday I listened to two presentation from working groups within our Health System.  Their goal: figure out how to make sure that at the time of hospital admission, every patient's home medications are either continued, discontinued or modified as the result of a conscious action - rather than by accident.  The experience was inspiring and humbling at the same time.  Each team was comprised of the right people with the right tools.  Physicians. Nurses. Pharmacists. Experts in process design.  And all of them skilled, experienced and highly motivated. They had a year to work.  And their efforts were magnificent.  Nonetheless,  their statistical results told us that they were only modestly successful in reaching their goals.

Driving home, I had three thoughts.  First, a decade after the first halting efforts led to a national, and then an international movement to make healthcare safer, we still have a long way to go.  Second, as in every other aspect of patient safety, there is no substitute for patient and family engagement.  Hospitals and health systems can build databases and computerized decision support to try to prevent errors, but there is nothing like an involved son, daughter or spouse keeping careful track of what medications have been prescribed and in what doses, why they were prescribed, what side effects to watch out for.

Finally, and here's the pediatrician talking, it wouldn't be so darn hard to keep track of each patient's medications if we didn't prescribe so many.  This isn't so trivial a point as it sounds.  A number of studies have cited the untoward effects of "polypharmacy," especially in the elderly.  And investigators have found in these cases that a large proportion of medications could be discontinued without ill effect.  Yes, once again, in healthcare, less CAN be more.