Health care delivery is changing rapidly and that brings new opportunities for error, according to a speaker at the 34th midyear clinical meeting of the American Society of Health-System Pharmacists (ASHP), held in Orlando, Florida, from December 5 to 9, 1999. Almost 16,500 people gathered at the Orange County convention centre for the meeting, including participants from 35 countries. This three-page report, contributed by Laurence Goldberg (consultant pharmacist) and Christine Clark (medical writer) looks at some of the topics covered |
Orange county convention centre, Orlando |
Automation had the potential to introduce new types of medication errors, according to Dr Sue Proulx (vice president - operations, Institute for Safe Medication Practices [ISMP]).
Typical problems reported to ISMP included software that printed incorrect characters, software that added terminal zeros or failed to add leading zeros and systems that did not link intravenous doses with other medication listings. Some automated systems still allowed the nurse to select more than one patient's medication at a time and mix-ups had occurred as a result. Items could be removed from some machines even though they had not been prescribed. Medicines could also be returned to the wrong location in some types of machine, in certain circumstances, leading to incorrect selection later.
Newer systems, some using bar code technology, had been designed to overcome some of these deficiencies, said Dr Proulx. However, it was of prime importance that the pharmacist checked all computerised prescriptions before automated dispensing took place.
At a dinner hosted by the ISMP, Dr Linda Kohn (project co-director, quality of care in America project, Institute of Medicine [IOM]) described some of the thinking behind the recent IOM report entitled "To err is human: building a safer health care system". Dr Kohn relayed what one doctor had said to someone who believed that her relative had been the victim of a medical error: "Bad things happen at evenings and weekends".
The IOM, she explained, was a private, non-profit agency, founded in 1970, which undertook policy analysis. It was part of the National Academy, whose charter dated from the time of Abraham Lincoln. The recent study was not commissioned by any outside body, and it was part of a larger project concerned with quality in health care.
Health care delivery was changing rapidly and that brought new opportunities for error, said Dr Kohn. It was estimated that 44,000-98,000 Americans died annually as a result of medical errors at a cost of at least $17bn (£10.6bn). Medication errors were estimated to account for 7,000 deaths annually.
Errors embraced both failures to complete planned action (errors of execution) and failures to plan appropriately (errors of planning).
The IOM report described the problem and also made nine recommendations.
One recommendation was the establishment of a centre for patient safety. The project team had considered the models of aviation and occupational health, both of which had made impressive progress. In 1967, the probability of death due to an aviation accident was one in two million but, by 1980, this had been cut to one in 80 million. Similarly, workplace deaths had been cut by half by the 1980s. Research and development was a well-funded and respected aspect of both these areas.
The centre for patient safety would, among other things, develop knowledge and understanding of errors and fund dissemination of information. Another recommendation was the establishment of a nation-wide, mandatory reporting system for medical errors. Reporting was a core area for improvement, said Dr Kohn.
However, she recognised that there was a delicate balance to be struck if public trust was to be preserved. Clinical providers needed an environment in which errors could be recognised and discussed while the public needed to know about accountability.
A national reporting scheme was proposed for the most serious errors. Although one third of states already had such schemes there was no consistency nation-wide. Furthermore, reporting alone was not enough. Dr Kohn said that it was essential to have the resources to analyse and respond to reports so that the best (and worst) practices could be understood.
This information should be made available to the public. The IOM believed that there was also a role for a voluntary, confidential reporting system separate from the national system.
Dr Kohn described two other important recommendations that had a direct bearing on pharmacy.
First, pharmaceutical companies should be required to test (using Food and Drug Administration approved methods) proposed drug names to avoid look-alike and sound-alike confusion with existing drug names.
Secondly, health care organisations should implement proven medication safety practices immediately. The report contained a list of safety practices drawn from the work of several other agencies. "There is no excuse for a health care agency to say that they don't know what should be done," concluded Dr Kohn.
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