Medication Errors Continue to Plague Hospitals

Tragic news yesterday as a 23-month-old girl died following an overdose of a blood thinner (Heparin) at Nebraska Medical Center. The story says “hospital officials are investigating,” but we already know what they will discover. This tragedy was preventable.

Medication errors concern
Percentage of ANA nurses who "worry" about medication errors (2007 survey).

Just ask actor Dennis Quaid. It was announced today that he is starring in a new documentary to help raise awareness about medical errors — three years after his newborn twins were given a drug overdose (also happened to be Heparin) at an L.A. hospital — which almost killed them.

Following is an article I wrote a few years back on medication errors. It’s a sad commentary on our healthcare system that these errors are still so commonplace. Prescription errors are so prevalent in hospitals and long-term care facilities that it has been estimated an average of one mistake per patient per day is made. Of course, most of these errors are not so serious as to lead to serious injury or death, but just ask yourself: are non-lethal errors any more acceptable?

-Dr. Terry Rondberg

Hospital admission = medication errors

By Terry A Rondberg, DC

According to an article appearing in the Archives of Internal Medicine, hospital admissions commonly produce medication errors, some with the potential to be harmful. Background information pointed out that although the admission process routinely includes a medication use history, errors in the history may mean a failure to detect drug-related problems, or lead to interrupted or inappropriate drug therapy during a patient’s stay.

While previous studies had suggested these errors are a potentially serious safety issue, the current study was designed to identify unintended discrepancies between physicians’ admission medication orders and a comprehensive medication use history, and the potential clinical significance of the discrepancy.

Patricia L. Cornish, BScPhm, of the University of Toronto, and colleagues screened medical charts from three months of admissions to the general internal medical clinics at an affiliated hospital. One hundred and fifty-one patients were included in the study who reported use of at least four medications and were either able to communicate or had a caregiver who could communicate for them.

A pharmacist or trained pharmacy or medical student visited patients after allowing 48 hours for clarification of admission medication orders and corrections of problems in the normal course of care. The team member conducted a thorough history of the patient’s regular medication use, relying on a patient or caregiver interview, an inspection of prescription vials, and follow up with a community pharmacy.

Discrepancies between physicians’ admission medication orders and the follow-up history were divided into four types of discrepancies: a drug omission, incorrect dose, incorrect frequency of dose, and an incorrect drug.

These were then further judged to fall into one of three classes of potential severity: Class one – unlikely to cause patient discomfort or clinical deterioration; class two – having the potential to cause moderate discomfort or clinical deterioration; and class three – with the potential to cause severe discomfort or clinical deterioration.

53.6% of patients had at least one unintended discrepancy.

“We identified 140 unintended discrepancies among these 81 patients,” wrote the authors. “The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.”

The authors concluded: “The data presented herein suggest that the processes for recording medication histories on admission to the hospital are inadequate, potentially dangerous, and in need of improvement. To improve patient care and minimize the potential costs of preventable adverse drug events, the health care system should explore ways to improve the accuracy of the hospital admission medication history.”

SOURCE: Patricia L. Cornish; Sandra R. Knowles; Romina Marchesano; Vincent Tam; Steven Shadowitz; David N. Juurlink; Edward E. Etchells: “Unintended Medication Discrepancies at the Time of Hospital Admission,” Archives of Internal Medicine, 165:424-429.