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Eliminate Errors


Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

Ensure Proper Medication Use

William Ford, MD, section chief of hospital medicine at Temple University Hospital in Philadelphia, offers these preventative suggestions:

  • Make sure you are writing the order for the right patient
  • If you have any questions, whether it’s dosing or scheduling of a medication, don’t be too proud to ask. Call the pharmacy or look it up in your pocket pharmacy guide
  • Don’t use abbreviations
  • Write legibly. “Doctors have notoriously horrible handwriting, only because we’re busy” Dr. Ford says. “I don’t think doctors have any special handicap to writing legibly. It’s just that we’re lazy, and we scribble. … Take your time.”
  • Reconcile medication at transitions of care. When patients are admitted or discharged, make sure you reconcile their medications. Make sure patients are going home on the medications they should be going home on.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Wipe out Pediatric Medication Errors

The three most important steps pediatric hospitalists can take to avoid medication errors in infants and children:

  • Make sure the dose of a drug is weight appropriate;
  • Look for possible drug interactions;
  • Make sure the patient is not allergic to the medication requested.

“Pediatric drugs are almost always based on weight or some measure of size. That’s why the computerized physician order entry (CPOE) with decision support is especially important in pediatrics,” says William Bosco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. “Use the CPOE system, if you have one available. And if you don’t, that’s what you should be advocating to your hospital. The safer approaches may be seen as taking more time, but that little extra investment of time is going to make things safer for the patients.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH


1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. Published May 24, 2005. Accessed September 30, 2008.

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