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Computerizing prescription methods and applying good old shoe-leather epidemiology could be the best solutions to medication errors, one of the most common and costly threats to patient safety, according to William Jarvis, MD, associate director of program development in the Centers for Disease Control and Prevention’s (CDC) division of healthcare quality promotion. A medication error that causes patient harm is termed an adverse drug event (ADE), Jarvis recently told attendees at a patient safety-training course in Baltimore.
ADEs increase length of stay and result in a threefold jump in patient mortality. With patient safety a hot topic in recent years, the toll of ADEs is drawing national attention. Reasons typically cited for the lack of better prevention efforts in hospitals include that ADEs are tedious to monitor, detect, and report; health care workers are too busy; and the excuse that "it’s really no one’s job," he said. In addition to computer software, surveillance and prevention methods developed over the years in heath care epidemiology could help identify and reduce medication errors, Jarvis said.
Definitions of ADEs may vary in published studies, and there is little standardization in reporting the events, he noted. "We need to follow many of the same steps we did for health care-associated infections surveillance," Jarvis said. "We need to establish specific definitions. You [also] have the same problem with ADEs that you have with detecting health care-associated infections, and that is many of them are not readily detected by chart review. If we don’t detect them, we certainly [are not] going to learn anything about the epidemiology of these events or [find insights] to develop interventions," he pointed out.
A medication error can occur anywhere in the process, including ordering, transcribing, preparing, dispensing, administering, and monitoring. "The entire process — from the first initiation of writing the prescription all the way to administering the medication — is associated with ADEs," he said. "Not surprisingly, the largest percentage — almost half — occur during ordering." For example, a physician may omit the unit of measure, or he or she could write the name of the medication illegibly.
In addition, pharmacists may dispense the incorrect dose of a medication, or nurses may administer an incorrect medication or the correct medication at the wrong time. An example of a preventable ADE is failing to take a history and then giving a medication to a patient with a known allergy. "That is preventable," Jarvis said. "If a history had been taken, the drug would have not been given; the reaction would not occur."
One hospital found that ADEs cost $5.6 million a year, including $2.8 million for ADEs that could have been prevented, he said.1 "Based on these data, they extrapolated to the [U.S.] health care system and estimated that about $77 billion are spent annually on these ADEs. And that excluded long-term injury and malpractice claims that obviously would raise that number even higher."
ADEs vary by patient population, type of surveillance, definitions used, and evaluation or detection method. Another hospital study found that 6.5 ADEs were occurring per 100 admissions.2 "Of these, [more than] a quarter — 28% — were preventable," Jarvis said. "So I think our efforts in trying to reduce these can have a major impact."
The most promising approach to improving the situation is a transition to computerized physician order entry (CPOE), electronic prescribing systems designed to identify errors, he emphasized. "This really is a major way we can have impact on this problem," Jarvis said. Barriers remain to the implementation of CPOE, however, not the least of which is the initial cost of implementation. "It is not cheap to implement these systems, and we have to convince [hospital] administrators that the initial cost is well-worth the long-term benefit," Jarvis said. In addition, clinicians may be resistant to change their current systems, and computer resources typically are dominated by financial systems in hospitals, he noted.
Nevertheless, a consortium of Fortune 500 companies called the Business Roundtable has launched The Leapfrog Group, which encourages large employers to recognize and reward health plans and hospitals that improve patient safety. CPOE plans are a major priority with this group, and thus there is likely to be continuing pressure to adopt such systems. (See list of CPOE vendors in this issue.) The business group says the benefits of such computer systems include:
1. Gandhi TK, Seger DL, Bates DW. Identifying drug safety issues: from research to practice. Int J Qual Health Care 2000; 12:69-76
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274:9-34.