New Processes Can Help Hospitals Spot—and Stop—Drug Errors
By Carolyn M. Clancy, M.D.
March 6, 2012
You might think that your doctor would know if a new drug would cause bad side effects in combination with one you already take. Or that your pharmacist could tell if a prescription you thought was for Darvon, (a painkiller), really should be for Diovan (a blood pressure drug).
But with thousands of drugs (prescription and over-the-counter) of different strengths on the market, you could be wrong. When important information about medicines isn't communicated correctly at the right time, errors can happen.
Some of them can be very serious, even deadly.
Errors involving drugs are the most common type of medical errors, harming about 1.5 million people each year, according to the Institute of Medicine . Treating drug-related injuries that occur in hospitals costs $3.5 billion per year, according to its 2007 report.
A recent example shows how easily these errors can happen.
A 90-year-old woman was brought to a hospital emergency department (ED) after falling and breaking her hip. The woman's daughter gave a nurse her mother's medication bottles from home, including one for high blood pressure. Using that information, the nurse prepared a list of drugs for the woman's hospital stay.
Before the patient woman had hip surgery, a physician noticed that her blood pressure was too high. He increased the dosage of her blood pressure medicine from 75 mg to 100 mg. Shortly before her surgery, the woman went into cardiac arrest. She was successfully resuscitated, but her surgery had to be postponed.
Only when the woman was moved to the intensive care unit did another nurse notice that the dose level of the blood pressure medicine brought from the patient's home was actually 25 mg, not 75 mg. (The nurse in the ED had written the wrong dosage.) Fortunately, the woman recovered. Several days later, she was able to have the surgery to repair her hip and was discharged.
After identifying the error, the hospital staff did the right thing: They fixed the mistake, apologized to the patient, and launched a review to find out how similar mistakes could be prevented in the future.
One way the hospital might have avoided this error was to involve a hospital pharmacist. A pharmacist would have recognized that the type of blood pressure drug this patient brought from home did not come in the higher dose that was incorrectly listed on her chart.
More hospitals are working to reduce the chance of drug-related injuries with processes that involve pharmacists, doctors, and nurses.
One process is known as "medication reconciliation." This involves comparing a patient's current drug routine to any changes a physician makes when a patient is admitted, transferred, or released from the hospital. (Maintaining and communicating this information correctly is a national patient safety goal for 2012 of the Joint Commission , which accredits hospitals and health care organizations.)
In the case of the 90-year-old patient's blood pressure drug, medication reconciliation would have verified the patient's home medication list. The process would have also caught the difference between the real dose and the dose listed by the nurse in the ED.
To help hospitals with this process, the Agency for Healthcare Research and Quality (AHRQ) has funded research for a new toolkit based on a successful program at Northwestern Memorial Hospital in Chicago. Known as MATCH, the toolkit provides a step-by-step method so hospitals can review and improve current processes or create new ones. It can be used in both hospital and outpatient settings.
Even though more hospitals are working to prevent medication errors, patients have a role, too. Here's a checklist of tips that can help:
- Bring a list or a bag with all your medicines when you go to your doctor's office, the pharmacy, or the hospital.
- Ask questions. Ask your doctor or pharmacist to use plain language so that you understand the answers.
- Make sure your medicine is what the doctor ordered. Many drugs look alike and have names that sound alike. Check with your doctor or pharmacist to be sure you have the right medicine.
- Learn how to take medicine correctly. Read the directions on the label and other paperwork you get with your medicine. Ask your pharmacist or doctor to explain anything you do not understand.
- Find out about possible side effects. Many drugs have side effects. Some side effects may bother you at first but will improve with time.
If a side effect does not get better or you get a different one from what you've read about, talk to your doctor to see if you need a different medicine or dose.
Medicines can help you, but they can also harm you. Better medication reconciliation processes and smart questions from patients will reduce the chance of harm.
I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.
Agency for Healthcare Research and Quality
AHRQ Web M&M: Morbidity and Mortality Rounds on the Web
Medications at Transition and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
20 Tips to Help Prevent Medical Errors
National Academies of Science
Preventing Medical Errors: Quality Chasm Series
National Patient Safety Goals
Current as of March 2012
New Processes Can Help Hospitals Spot—and Stop—Drug Errors. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, March 6, 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/cc/cc030612.htm