Medication Errors: The Pain, The Problems, The Process
ASHP Meeting Focuses On Potential Causes, Solutions
Medication errors and the personal and professional devastation they cause took center stage at the 35th Midyear Clinical Meeting of the American Society of Health-System Pharmacists. For the record crowd of 20,000 attendees who flocked to Las Vegas, the message was clear from the opening session to the closing banquet: Too many people are dying or suffering because of flaws in the drug-use system, and pharmacists must act now to prevent as many problems as possible.
"Medication and medical error rates are substantial," explained Gordon Sprenger, chief executive officer of the Allina Health System in Minnesota. "We must get away from debating whether 98,000 or 44,000 people die from them each year. We as health professionals feel that errors are outliers, that they are things that happen somewhere else. But the reason we haven't developed better systems is that we have such difficulty dealing with mistakes when they do occur. We expect perfection, to be infallible.... Each of us is accountable when an error occurs, but we work in a system, and the error is not possible unless the system also fails."
Patients, Families, Professionals Feel the Pain
Using a unique approach, the meeting's opening session featured a one-act play about an intravenous calcium overdose in a 7-year-old boy. A physician wrote an order for calcium gluconate 1,200 mg, but the pharmacist erred by supplying an admixture with 1,200 mg of elemental calcium. An astute mom noticed a change in the patient's mentation, and the impact of the error was minimized by prompt discontinuation of the I.V. solution and transfer of the patient to intensive care. Actors and actresses portraying the involved health professionals and parents offered insights into and analysis of the reactions, responses, and emotions typical in such situations.
Several speakers -- including one health care executive whose young daughter experienced three medication errors before dying of cancer -- stimulated ASHP members to think about ways they can make their health systems safer. Among the suggestions proffered were the following:
Acute Care: Problems Finding, Reporting Data
Few medication errors and other adverse drug events (ADEs) are formally recognized and recorded in U.S. hospitals, according to a new ASHP survey of pharmacy practice in acute care. Released formally at the meeting, the survey found that only 60% of respondents reported ADEs to external organizations.
When ADEs were reported externally, pharmacists were most likely to send the information to FDA (92%), followed by pharmaceutical manufacturers (27%), the United States Pharmacopeial Convention (USP; 17%), and the Institute for Safe Medication Practices (ISMP; 16%), however, as USP and ISMP are better equipped to publicize problems and seek solutions in practice, pharmacists should perhaps preferentially report to those organizations (see sidebar).
Pharmacists continued to rely heavily on nurses to monitor ADEs, with 96% of respondents saying that this is the most frequently used method of monitoring patients. Orders and medications that might indicate ADEs were monitored in 81% of hospitals and health systems, although routine review of laboratory orders is used in just 66% of locations.
Full results of the ASHP survey, which focused on medication therapy, monitoring, patient education, and wellness in acute care settings, were published in the December 1 issue of the American Journal of Health-System Pharmacy. A summary report is available from the survey's sponsor, Eli Lilly and Company, by calling 800-874-2778.
Come Up Short, but Shoot for Perfection
The analogy between errors in health care and the aviation industry is hard to ignore. After all, if the airlines had the same error rate as that found in medicine, one airliner with hundreds of people on board would crash each day of the year in the United States alone. CEO Sprenger recalled this scenario in his remarks, adding key differences: "In aviation, pilots are not penalized for reporting errors. But in health care, we tend to focus on the people surrounding the error, not on the systems problems... If we manage to a zero deficit for medical errors, then change will come. Will we ever achieve it? Probably not, but that's what we must set as our goal."
ASHP Meeting Focuses On Potential Causes, Solutions
Medication errors and the personal and professional devastation they cause took center stage at the 35th Midyear Clinical Meeting of the American Society of Health-System Pharmacists. For the record crowd of 20,000 attendees who flocked to Las Vegas, the message was clear from the opening session to the closing banquet: Too many people are dying or suffering because of flaws in the drug-use system, and pharmacists must act now to prevent as many problems as possible.
"Medication and medical error rates are substantial," explained Gordon Sprenger, chief executive officer of the Allina Health System in Minnesota. "We must get away from debating whether 98,000 or 44,000 people die from them each year. We as health professionals feel that errors are outliers, that they are things that happen somewhere else. But the reason we haven't developed better systems is that we have such difficulty dealing with mistakes when they do occur. We expect perfection, to be infallible.... Each of us is accountable when an error occurs, but we work in a system, and the error is not possible unless the system also fails."
Patients, Families, Professionals Feel the Pain
Using a unique approach, the meeting's opening session featured a one-act play about an intravenous calcium overdose in a 7-year-old boy. A physician wrote an order for calcium gluconate 1,200 mg, but the pharmacist erred by supplying an admixture with 1,200 mg of elemental calcium. An astute mom noticed a change in the patient's mentation, and the impact of the error was minimized by prompt discontinuation of the I.V. solution and transfer of the patient to intensive care. Actors and actresses portraying the involved health professionals and parents offered insights into and analysis of the reactions, responses, and emotions typical in such situations.
Several speakers -- including one health care executive whose young daughter experienced three medication errors before dying of cancer -- stimulated ASHP members to think about ways they can make their health systems safer. Among the suggestions proffered were the following:
Kevin Roberg, the health care executive who is general partner with Delphi Ventures, told ASHP members, "Kelsey's mom and I wanted to know what happened. We wanted to make sure that no other child had to go through what Kelsey did. But we know that the same errors happen today."
An unidentified nurse whose remarks were read by an actress talked about the advantages of using a standardized chemotherapy order form in her institution, which reduced the number of interventions pharmacists needed to make by 75%. She encouraged use of such standardized orders for heparin and insulin protocols. "The team is everything," she closed. "As a team, we are one."
"Find physician advocates for improved medication safety," added Jay McNitt, MD, of Houston, Tex., in prepared remarks read by an actor. "This is about protecting patients, not turf." McNitt advocated special attention on two typical problem areas: oncology and pediatrics. "Lead with us," the physician concluded. "Pharmacists are the medication experts. We'll play our part, but we need you."
A technician asked Children's Hospital and Clinics pharmacists why policy allowed oral liquid doses of more than 20 mL to be dispensed in syringes designed for injection but smaller doses had to be dispensed in oral syringes. Mark Thomas, director of pharmacy, told the ASHP meeting that he quickly approved a switch to cups for larger doses of liquids, recognizing the inherent inconsistency and possibility for error.
"Think about what can go wrong and avoid it," advised Timothy S. Lesar, PharmD, director of pharmacy at New York's Albany Medical Center. "Change provides the opportunity for further change. This is an evolutionary process, one that began long ago and for which one act provides the seed for the next."
Acute Care: Problems Finding, Reporting Data
Few medication errors and other adverse drug events (ADEs) are formally recognized and recorded in U.S. hospitals, according to a new ASHP survey of pharmacy practice in acute care. Released formally at the meeting, the survey found that only 60% of respondents reported ADEs to external organizations.
When ADEs were reported externally, pharmacists were most likely to send the information to FDA (92%), followed by pharmaceutical manufacturers (27%), the United States Pharmacopeial Convention (USP; 17%), and the Institute for Safe Medication Practices (ISMP; 16%), however, as USP and ISMP are better equipped to publicize problems and seek solutions in practice, pharmacists should perhaps preferentially report to those organizations (see sidebar).
Pharmacists continued to rely heavily on nurses to monitor ADEs, with 96% of respondents saying that this is the most frequently used method of monitoring patients. Orders and medications that might indicate ADEs were monitored in 81% of hospitals and health systems, although routine review of laboratory orders is used in just 66% of locations.
Full results of the ASHP survey, which focused on medication therapy, monitoring, patient education, and wellness in acute care settings, were published in the December 1 issue of the American Journal of Health-System Pharmacy. A summary report is available from the survey's sponsor, Eli Lilly and Company, by calling 800-874-2778.
Come Up Short, but Shoot for Perfection
The analogy between errors in health care and the aviation industry is hard to ignore. After all, if the airlines had the same error rate as that found in medicine, one airliner with hundreds of people on board would crash each day of the year in the United States alone. CEO Sprenger recalled this scenario in his remarks, adding key differences: "In aviation, pilots are not penalized for reporting errors. But in health care, we tend to focus on the people surrounding the error, not on the systems problems... If we manage to a zero deficit for medical errors, then change will come. Will we ever achieve it? Probably not, but that's what we must set as our goal."
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