Did you know that medication errors are the most common medical mistakes
that occur in hospitals?
Studies indicate that 400,000 preventable
drug-related injuries occur each year in hospitals and another 800,000 occur in long-term care settings.
Most mistakes are caused by illegible handwriting, misinterpreted orders,
personnel fatigue, a pharmacy dispensing the wrong drug, errors in the
administration of the drug, and even misplaced decimal points.
“Let’s say a physician writes a prescription for Colchicine
and accidentally orders ‘10.0 mg,’ when he should have ordered
‘1.0 mg,’” writes Leah Binder for
Forbes. “That’s a tiny decimal error, a mistake even the best doctor
could make. But it can be catastrophic for the patient. The higher dose
could cause Colchicine poisoning, similar to arsenic poisoning: burning
in the mouth and throat, excruciating abdominal pain. Internal organs
would melt away and death would likely occur within 24 to 72 hours.”
Another problem? Too many links in the chain between the doctor who orders
the drug and the staff that dispenses the drug to the patient. Each time
an order gets passed from one person to another, there is another opportunity
for a mistake to occur.
Errors in administering powerful drugs like blood thinners, insulin, and
narcotics can lead to serious injury and even
death. A recent
study reveals that medication mistakes may be reduced significantly by employing
electronic prescription drug ordering systems (computerized physician
order entry, or CPOE) that provide dosage assistance, allergy and interaction
alerts, and patient identifiers—all things that can be lost with
a manual system that relies on humans to ensure the correct decisions are made.
The findings, published in the March issue of
The Journal of Psychiatric Practice, outline how the psychiatric unit at Johns Hopkins Hospital cut its error
rate from 27.89 per 1,000 patient days to 3.43 per 1,000 patient days
by using an electronic medication system and improving error reporting.
This study is consistent with other published research that indicates
medication errors can be reduced by more than 50 percent with the use
of electronic ordering systems. Hospitals can also reduce errors by instituting
best practice guidelines and ensuring their staff follows those guidelines
each time they dispense a drug.
“[R]esearch suggests errors decline by as much as 85 percent when
hospitals implement CPOE, yet the pace of adoption in the hospital industry
is agonizingly slow” writes Binder on September 3, 2013. “To
jump start progress, the federal government used economic stimulus funds
starting back in 2009 to incentivize hospital investment in CPOE and electronic
medical records (EMRs). That improved the pace of change, but still, most
hospitals are in the Dark Ages when compared to other industries like
airlines or retail.”