Medication errors have been a healthcare issue for many years, but were really thrust onto the national stage in 1999 when the Institute of Medicine (IOM) released a report called “To Err is Human”.
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In that report, they estimated that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors. Even when using the lower estimate, deaths in hospitals due to preventable adverse events exceed the number of deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516). One area that the report identified to improve patient safety was the potential for hospitals to use computerization and automation to decrease the risk of medication errors.
For example, since many of these errors are the result of poor handwriting, transcription errors, miscommunication among providers, and drug interactions, it was suggested that computerized physician order entry (CPOE) could potentially reduce errors that occur due to these events by requiring that each provider type in orders for patients. Additional safety could be seen by using the computer system’s clinical decision support which helps physicians reduce the occurrence of potentially harmful drug interactions and other types of medication errors.
Other forms of technology that were recommended included using bar code scanners to verify medication prior to administering it to patients since the drug administration step is the last step, and so called “smart infusion pumps” to administer IV medication as these pumps have software to check dosages so that accidental overdoses are less likely to occur.
All of these items have value as they can each help decrease medication errors, and many hospitals have adopted these technologies, According to a national survey, 15.4% of hospitals have implemented CPOE systems with clinical decision support software, 30.9% of hospitals use bar code assisted medication administration, and 60% of hospitals use smart pump technology.
Implementing all of these technologies together, or what is called a closed-loop system, which includes having the physician use CPOE to order medication, have the pharmacist review and validate the medication order, and have the nurse chart the medication administration using bar-code scanning technology has been called the ideal combination of technologies for preventing medication errors. However, very few hospitals across the country actually have all of them in place. Union Hospital is among an estimated 6% of all hospitals in the country that has all of these technologies working together to help assure our patients’ safety. This focus on patient safety was one of the things that drew me to Union Hospital. But we can not be complacent; technology alone is not enough to keep our patients safe. There are ways to work around some of the safety that these systems provide by not using them appropriately or not recognizing, or not reporting, when these systems contribute to as opposed to stop errors.
David Jaspen, RPH, CCP
Director of Pharmacy