Medication errors are common.
Here’s how to hold the system accountable

Medication errors hurt more hospitalized patients than any other mishap, including botched surgeries and health care-acquired infections. In long-term care, they have been found to be the second largest source of harm.

Even patients taking medications at home frequently make a mistake and miss a dose or take the wrong amount or drug. Not all medication errors cause serious harm, but some are fatal and many result in the need for costly additional care.

News coverage tends to focus on sensational instances of alleged individual wrongdoing, such as an Ohio physician who was tried for giving overdoses of fentanyl and a nurse at Vanderbilt University Medical Center in Nashville who was convicted of homicide for accidentally administering a powerful paralytic agent.

Less attention is paid to ways that health care facilities, technology vendors and pharmacies fail to safeguard patients from inevitable human error. 

Here are three systemic problems that journalists can highlight in their reporting about medication errors.

1. Processes that should protect patients are flawed

Rita Jew

Rita Jew, Pharm.D. Photo courtesy of Rita Jew

Many hands are involved in medication use:  physicians write orders, pharmacists confirm and fill them, and nurses, patients and other caregivers administer drugs. 

All are supposed to follow the mantra of the “five rights”: right patient, right drug, right time, right dose, right route. But they can’t achieve that outcome without appropriate processes and conditions, including adequate staffing.

Cases in which providers intentionally cause harm are “really rare situations” with “multiple bad processes and systems that contribute,” said Rita Jew, Pharm.D., president of the Institute for Safe Medication Practices, a not-for-profit that issues guidelines for health care providers and consumer advice

Rather than focus on people, Jew said,  journalists should “keep asking the whys. Why did it happen? How did it happen? What went wrong with the system?”

The Vanderbilt case is an example of multiple system failures, some of which are common among hospitals. They were described in a CMS Statement of Deficiencies and Plan of Correction

A major factor was that an automated dispensing cabinet was programmed with an override that allowed nurses to grab a dangerous neuromuscular blocking agent, vecuronium, without a prescription. That’s a no-no under safety standards set by ISMP and the Joint Commission, a health care accrediting body. Another big problem was that the hospital had not implemented barcode scanning to verify medications in all of the departments, including the one where the deadly drug was administered.

2. Older people take lots of drugs, and no one’s keeping track

Between 1988 and 2010, the proportion of adults ages 65 and older who took five or more medications, known as polypharmacy, tripled to 39%. More drugs mean more potential for adverse reactions and errors. 

Another nagging issue is that hospitals do an astonishingly poor job of keeping track of what patients take. ECRI, a not-for-profit patient safety organization that is affiliated with the ISMP, has placed inaccurate patient medication lists among its top patient safety concerns.

Some electronic health systems incorporate the Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults, which lists medications to avoid in most older patients. Tools such as MedSafer, software developed in Canada, can help physicians eliminate drugs that do more harm than good

But deprescribing is an ongoing battle in a system designed to put patients on drugs, not take them off. The U.S. Deprescribing Research Network and the Bruyère Research Institute in Canada are among organizations addressing that challenge..

In a different approach, Harvard Medical School’s Gordon Schiff, M.D., created a program to promote conservative prescribing. His co-written paper, Principles of Good Prescribing, advises physicians to resist marketing and use only a few drugs that they know well.

3. Technology creates new hazards

Health care is plagued with poorly designed technology. Numerous devices that are supposed to improve safety don’t always work as intended. 

Case in point: computerized prescriber order entry. In his book, The Digital Doctor, Robert Wachter, M.D., chair of the department of medicine at the University of California, San Francisco, explains how a state-of-the-art electronic system allowed a teenager to receive 38 1/2 tablets of an antibiotic rather than the standard dose of one. The elemental glitch: the doctor who ordered the prescription failed to realize that the default was set to “milligrams per kilogram” rather than “milligrams.” (The boy had a grand mal seizure but ultimately recovered). 

In fact, a rush to  computerized ordering systems in the 2010s reduced medication errors overall but also created new types of errors — most often erroneous dosing, misrouting and duplicate orders, an FDA study showed. Other documented technology hazards are defective “smart” infusion pumps and outpatient pharmacy ordering systems that automatically refill discontinued medications.   

Although technology has arguably improved, numerous deficiencies remain. 

“There is a lot that journalists can do to get consumers to ask the right questions and get vendors to do the right thing,” Jew said.

What to know about medication error rates

Watchdog organizations rely on “signals” from mainly voluntary reports to detect medication safety problems, with the understanding that a few errors or near misses reflect many more that are unreported. Hence, we can’t know precisely how many errors occur. One public repository accessible to journalists is the FDA’s adverse event reporting system, which triggers the agency’s safety alerts. Private groups such as the ISMP and the Joint Commission maintain their own confidential reporting systems and use them as the basis of recommendations and sentinel event alerts, respectively.

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