Reducing Medication Errors - Industry Trend or Event

Health Management Technology, Jan, 2001 by Salvatore M. Barcia

Does it matter what pharmacy computer system you choose?

It can happen at any time in any hospital in America. One of the thousands of doses that a hospital prepares and administers may be in error. Sometimes the results are minor or benign; other times they are catastrophic.

Medication errors may occur at any juncture in the medication process. Usually they are the result of multiple errors being made in the many steps of the medication process. Several years ago, a Sunday New York Times Magazine article discussed a fatal overdose of digoxin to a pediatric patient. The article correctly focused on the failure of a system when a serious medication error occurs, declining to point fingers of blame. Studies suggest that as many as seven out of 100 doses administered are in error. Many of these errors go undetected, quite literally buried with the patients killed by the error.

"I don't care if you are the best pharmacist, nurse or physician. Medication errors will occur. We are all human, and we all make mistakes," says Mike Cohen, president of Institute of Safe Medication Practice (ISMP). Cohen founded ISMP with a singular purpose: to reduce medication errors. His monthly newsletters, which focus on specific drugs, doses and packaging that can cause errors, are widely distributed by his non-profit company.

Clearly, reducing medication errors requires a multi-disciplinary layered approach, replete with overlaps and appropriate checks and balances. Pharmacy computer systems have been identified as an integral component in the challenge to reduce medication errors to zero. In a well-structured health system environment, the pharmacy department functions as a sentinel of pharmaceutical care. Make no mistake about it: Pharmacists, by far, possess the most in-depth education in pharmacology and related subjects. However, even pharmacists cannot possibly possess a command over all aspects of the nearly 10,000 generic entities that exist in medicine today. They need the assistance that only computers can provide.

There are vast differences in the quality of clinical screenings that even the best pharmacy computer system offers today. Although all pharmacy software vendors use commercial sources for their clinical data, each vendor must design and code its own methodology for using that data. Differences from vendor to vendor include clarity and ease of use of each screening module, as well as the actual number of these modules that the vendor provides. These modules include drug-drug interactions, drug-food interactions, dose range modules, allergy screening, duplicate drug detection, geriatric and pediatric specific features, IV compatibility checks, drug disease contraindications and many others.

Many systems also offer methodology for users to program intelligent rules into the pharmacy system to screen for factors not incorporated into the vendor's modules. These rules-engines can include combinations of drug- and patient-related factors. They can address individual pharmacy policy and procedures, and P&T committee recommendations. Along with clinical screenings, this brings consistency to the clinical process by facilitating participation in clinical decisions by all pharmacy department members.

Also, there are a plethora of support references available for pharmacists when they need to access additional information, many available electronically. The best pharmacy systems integrate references, so pharmacists do not have to interrupt their workflow to access off-line data.

At the heart of an excellent pharmacy system is the ability for pharmacists to document clinical interventions online. This tool allows pharmacy clinical managers to assess the effectiveness of clinical programs designed to optimize outcomes, contain costs and reduce risk. Additionally, flexible reporting tools must exist to make good use of this data.

It is essential that pharmacists and other clinicians be allowed to choose the best tools designed to reduce risk. Far too often, IS managers flex their administrative muscle by insisting on specific technologies that will help them meet enterprise objectives, but which hinder specific departments in their quest for excellence. In this era of staff reductions and consolidated middle management in hospitals, too many pharmacy directors go along with decisions that compromise patient care, all in the guise of being a team player.

Many studies suggest that hospital administrators are so far detached from daily operations that they are unaware of the strong potential for medication errors at their facilities. It is far easier to terminate the person who makes an error, and his manager, than to analyze and correct deficiencies in the overall system.

Medication error reduction must be a mindset of every person even incidentally involved in the medication process, including IS managers and support staff. Too many IS managers and analysts forget that they do not have the background necessary to select clinical systems. Could you imagine the best surgical or diagnostic tools not being employed because someone in engineering wanted to standardize brands or methodologies--that would be absurd. Yet, hospitals do that very same thing in pharmacy on a daily basis. Far too often the pharmacy computer systems that best prevent medication errors are passed over in favor over a single vendor solution, or what IS perceives as a better technological fit. It is in these situations that IS has lost its focus of being a support department to help the hospital meet its mission.