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Prevention of Medical Errors 3
2 CEUs Prevention of Medical Errors

Section 5
Preventing Medication Errors in Hospitals through a
Systems Approach and Technological Innovation:
A Prescription for 2010

Question 5 | Test | Table of Contents

The U.S. spends over $1.6 trillion on healthcare. Yet, Americans pay much more for medical treatment than anyone else in the world, and also experience some of the highest medical errors rates of any industrialized nation (Heavey 2005; Schoen et al. 2005). In fact, $300 billion is spent each year on healthcare that does not improve patient outcomes—treatment that is unnecessary, inappropriate, inefficient, or ineffective (Bush 2004). The Institute of Medicine (IOM) estimates that medical errors alone cost the U.S. over $37 billion each year. Yet research shows that most medical errors are largely preventable (Meadows 2003).

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare provider or patient. Medication errors have been found to be one of the most common causes of medical death, costing the lives of over 7,000 patients each year (Meadows 2003). Many more suffer permanent disability because of medication errors. Yet medication errors are considered the most preventable of all medical errors (Oren, Shaffer, and Guglielmo 2003).

Causes of Medication Errors
Contrary to popular belief, medication errors are not typically the result of negligent or incompetent healthcare providers. Instead, experts contend that medication errors are a direct result of how the health system is organized and how care is delivered (Migdail 2000; Leape, Epstein, and Hamel 2002). When a patient enters a hospital for treatment, they are exposed to an outdated, paperbased system that is highly fragmented, highly variable, and error prone (Nielsen et al. 2004; Olsen 2002; Institute of Medicine 2001).

Therefore, all relevant medical information is rarely available in one location in real-time when the patient requires care. The result is that patients are seen by doctors who generally do not have access to patient records, including current treatments, medications, and allergies.

Typically, physicians keep information about drugs, drug interactions, managed care formularies, clinical guidelines, and recent research in memory and not in documented form. Medical orders and prescriptions are handwritten and are too often misunderstood or not followed in accordance to physician instructions.     

Available Solutions to the Problem
 There are numerous available solutions to the medication error problem in hospital settings. But often, many of the solutions are being used in isolation rather than through a integrated systems approach. Some focus on better staff training, while others focus on better error tracking and reporting, adopting the best practices from highly reliable industries, involving system redesign, and involving the use of emerging technologies (Al- Assaf et al. 2003).
One system-based solution is called failure mode effects analysis (FMEA). This is a systematic group ofactivities intended to do three things: {a) recognizeand evaluate the potential failures of a product orprocess and the effects of those failures, [b) identifyactions that could eliminate or reduce the chance ofpotential failures occurring, and (c) document theentire process (Reiling, Knutzen, and Stoecklein2003). Many industries have successfully usedFMEA for systems improvement.

In fact, FMEA hasbeen used in healthcare for system improvements inthe field of anesthesiology, where mortality resultingfrom errors has been reduced by 95% over the past15 years (Orkin 1993). Unfortunately, FMEA is notbeing used to improve medication safety. Without asystem-wide medical informatics program where allpatient information is shared and updated across allrelevant departments, FMEA is not likely toimprove the medication error problem by itself.

Another proposed solution is electronic medical records (EMRs). With EMRs, physicians can easily access a patient's medical records to check any current medications the patient is on, and probe for any allergies or adverse drug interactions. A very basic EMR system replaces all paper charts with fully electronic medical records. Moreover, EMRs can be made available to the patient via smart card technology or even by implanting it into the patient and can be electronically scanned and uploaded into a hospital's computer system (Grant 2005).

Experts suggest that electronically entering all medical information, such as admission narratives, laboratory tests, radiology studies, and nurse and physician notes, and storing this information on EMRs can vastly increase the safety of the healthcare encounter. One such study found that compared to paper-based systems, EMRs reduced medical errors by 55% (Wendel 2000). But according to one study, no more than 25% of U.S. hospitals and 20% of doctors' offices have adopted electronic medical records (Hillestad et al. 2005).
Comprehensive decision support systems (DSSs), with real-time medical informatics obtained from a patient's EMRs, is deemed one of the prime strategies for reducing medication errors in the future (Wilson et al. 2005). These systems allow for improved communications with clinicians, access to medical knowledge, technique monitoring (including remote monitoring), automated calculations, patient information sharing, and error tracking and reporting.
Another proposed solution is computer physician order entry (CPOE) programs. Clearly, illegible handwritten prescriptions, overlooked allergies and drug interactions, and incorrect dosage often lead to medication errors. CPOEs have been found to be effective in reducing such medication errors (Oren, Shaffer, and Cuglielmo 2003). CPOE involves entering medication orders into a computer system rather than verbally or on paper.
Another solution to reducing medication errors is the use of bar coding technology. Bar coding technology used in conjunction with EMRs can prevent even more medication errors. For example, once a prescription order is checked against the electronic medical records, it is routed to the hospital pharmacy, where medication is labeled with the patient's name and unique barcode. The nurse scans the barcode on the medication, and then scans the bar code on the patient's wrist band, assuring that it is right medication in the right dose for the right patient, virtually eliminating errors (Meadows 2003).

Optimal Solution
To date, no hospital has put together an innovative and integrated solution to the medication error problem. What is proposed here is a novel but optimal solution. It involves the implementation of FMEA as a starting point. FMEA will examine the system to pinpoint failures or potential failures in the process of ordering and dispensing medication, identify actions to reduce the chance of failure, and document the entire process.

However, to be effective, FMEA must be used conjunction with the development and implementation of an innovative system-wide decision support system (DDS), which will include real-time medical informatics as well as the integration of EMRs.

Medication errors are system problems requiring system-wide responses. A comprehensive support decision driven by real-time medical informatics coupled with the emerging technologies outlined in this article (i.e., CPOE, ADMs, bar coding) is the optimal solution for preventing medication errors in hospitals. This will require changes in both healthcare organizational design and delivery, as well as a time and financial commitment.

However, the resources will be well spent if even one life is saved. Moreover, pragmatic cost and benefit analysis demonstrates the use of this proposal. Patients deserve to be safe in our healthcare system; this innovative solution will provide that safety.
-- Crane, J., & Crane, F. G. (2006). Preventing Medication Errors in Hospitals through a Systems Approach and Technological Innovation: A Prescription for 2010. Hospital Topics, 84(4), 3-8.

Personal Reflection Exercise #5
The preceding section contained information about preventing medication errors.  Write one case study example regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Peters, E., Slovic, P., Hibbard, J. H., & Tusler, M. (2006). Why worry? Worry, risk perceptions, and willingness to act to reduce medical errors. Health Psychology, 25(2), 144–152. 

Schüz, B., Wurm, S., Ziegelmann, J. P., Warner, L. M., Tesch-Römer, C., & Schwarzer, R. (2011). Changes in functional health, changes in medication beliefs, and medication adherence. Health Psychology, 30(1), 31–39.

Tsai, M., Mandell, T., Maitland, D., Kanter, J., & Kohlenberg, R. J. (2016). Reducing inadvertent clinical errors: Guidelines from functional analytic psychotherapy. Psychotherapy, 53(3), 331–335. 

What are the three things that FMEA does? Record the letter of the correct answer the CE Test

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