Simple solutions can reduce medication errors

Simple solutions can reduce medication errors


>>Fortunately, the
vast majority of medication errors
never result in a significant
impact for patients. But, overall, the
number of patients who are injured every
year is very significant. About 1.5 million Americans
experience drug-induced injuries that are preventable every year. Approximately 1 in every 400
hospitalizations is associated with a medication error that
adversely impacts patient care. And the economic
impact is very large. If you just look at the added
medical care cost associated with medication errors,
it adds about three to five billion dollars to our
health care costs every year. And that doesn’t account
for the impact in the loss in productivity of those
people that are affected. If you add that into the
equation, it’s in the tens of billions of dollars. And some estimate that it’s
even over $100 billion. There’s a large social
impact to that, as well. First of all, the
patients and their families that experience a
medication error, they often lose their trust
in the health care system, which may make them less likely to seek medical care
when they should. Also, when they enter into
the medical care system again, they’re going to do so with a
significant amount of anxiety. But there’s also a big impact
on the health care providers who are involved in
a medication error. They feel a lot of guilt. There’s a loss of confidence
in their clinical competency. Probably the most extreme
example of that is a recent case where a nurse administered
a wrong medication, and it was a very severe
outcome for the patient. And that burden of
that was so great that that nurse attempted
suicide. So there’s a huge impact
on the health of patients, economically, sociologically,
such that it’s imperative that we really invest
significant resources and time to address the issues
of medication safety. [ Silence ] There’s several things that
contribute to medication errors. We know that over 50 percent
of medication errors occur in the area of ordering
and transcribing. So a wrong drug is ordered. A physician doesn’t recognize
that there’s a contraindication in that particular patient or doesn’t recognize
a drug interaction or in the transcribing process between one health
professional and another. About 25 percent of medication
errors were due to confusion of drug names, either
written or orally. We also know that the
work environment can be very important. A work environment where
people are distracted, where there’s a lot of interruptions is an
environment that’s prone to errors. [ Pause ] One very significant way
that we can reduce errors is to incorporate what’s
called e-prescribing, using electronic mechanisms
for prescribing drugs. Right now, less than 20 percent
of physicians use e-prescribing, even though even
though 90 percent of pharmacies are capable of receiving electronic
prescriptions. And this can reduce errors that
come from hearing drug names that are similar and
confusing them, which account for about 20 percent or
more of medication errors. It also prevents
problems that relate to illegible prescriptions, whereas another source
of confusion. [ Pause ] Another thing that
can be done is by standardizing
equipment and procedures. As you’re probably aware,
hospitals utilize pumps when they administer
intravenous medications. And often a hospital
will use a wide variety of pumps within their system. So the nurse going from
one floor to another or from one patient to another
may have to change the type of pump they’re using. And that’s just a setup
for errors to occur. Standardization of
protocols is important. Sometimes a drug in one unit
is prescribed using volume; in another unit,
using mass or weight. And those types of things,
again, confuse people as they shift from one area
of the hospital to another. Another way that you can reduce
medication errors is just utilizing the full expertise
of the entire health care team. A study in 1999 demonstrated
that, simply by having a pharmacist
on the medical rounds in a hospital, can reduce
by 66 percent the number of medication order errors. [ Pause ] Humans are going
to make mistakes. And what we need to do is
we need to create a system where a human mistake doesn’t
result in a human tragedy. We need to look at
the health care system from a holistic approach
and recognize that, when errors occur, whether
they’re medication errors or other medical errors, the
objective should be not to find who do we blame but to find
the problem in the system and address it from a systems
approach, much as we do in the airline industry. We want to have enough
safeguards in place that a single human error
doesn’t get transmitted throughout the whole
system and, ultimately, then, reach the patient. [ Pause ] We recently found that, every
time a patient is handed off from one area in a hospital
to another, we see an increase in the number of errors. So a patient coming from — as an outpatient and coming
into the emergency room, there’s a certain percentage
of medication errors. Now, when you take and move that
patient from the emergency room to the critical care unit, the number of errors
actually increased. Going from the critical care
unit to the step-down unit, there are additional errors;
and then down to a regular unit. So this transferring of
patients from one unit to another is a key area
that we need to work on. Now we know that’s a
major source of errors. We need to identify strategies
to prevent those errors. [ Pause ] Another area of research
is looking at the issue of health
literacy . If you look at the outpatient
population of medication use, much of it is self-directed. Patients have to be able
to understand labels in over-the-counter medication and also prescription
medications. And we make an assumption that
people can understand them. There’s a lot of
research now being taken as how do we best structure
physically those labels so that people can read
them appropriately and pick up the right messages
that they need to and prevent confusion
between medications. Many patients today are taking
five and four medications. We need to make sure that they’re taking each one
appropriately at the right time. [ Pause ] As we see the baby boomers
coming to senior citizen age and increased need
for health care, we’re going to see
a greater stress on our health care system. In addition, as a nation,
we’re becoming more aware of the underserved population:
people who need health care but, for financial or other reasons,
don’t have access to it. And, as we bring
those individuals into the health care system, the volume of patients being
treated is going to increase. And that, again, is a setup
for errors, medical errors and, specifically, medication errors. Also, there’s going to
be greater complexity in the drugs that are used. We’re learning more and more about how genetics
influence the way that people respond to drugs. And we already have some drugs
where, before they’re used, there’s a genetic test. And that genetic test maybe
determine whether the drug will be a right choice
for that patient, or the genetic test
may determine how much of that drug should be given. So the complexity of deciding
what drug to what patient at what dose is increasing
as we learn more and more about how patients respond. And those types of
things are going to require more highly trained
health care providers to be able to oversee that system and
a much more careful system that has the right
checks and balances to prevent errors
from occurring. [ Silence ]

1 Reply to “Simple solutions can reduce medication errors”

  1. Nice video. You may also want to checkout the review of simple solutions on my blog at kevinreviews. com/simple-solutions-review/ Thanks, Thorny.

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