By Rob Stein, Washington Post Staff Writer
Computer systems designed to prevent medication errors in hospitals can actually contribute to mistakes, according to a new report.
As more hospitals have implemented automated systems for administering drugs, the number of errors associated with them has risen, according to an annual report on medication errors released yesterday by the U.S. Pharmacopeia (USP), a nonprofit group that sets standards for the drug industry.
"It would seem logical that applying computer technology to the medication use process would have a significant positive impact in preventing medication errors," said Diane Cousins, vice president of USP's Center for the Advancement of Patient Safety. "Yet, depending on the computer's design or user competence, new points of potential errors can emerge."
The findings should help hospitals that have adopted the systems find ways to reduce errors, and those considering such systems to implement them more safely, Cousins said. As the technology matures, the number of errors is likely to decrease and the technology should eventually make hospital care overall safer, she said.
Many hospitals have been adopting computerized systems for administering drugs to patients in an attempt to reduce errors, especially since a landmark 1999 Institute of Medicine (news - web sites) report estimated that between 44,000 and 98,000 hospitalized Americans die each year from medical errors of all kinds.
USP has been collecting medication error data from hospitals on a voluntary basis for the past five years. In the latest data, 570 hospitals and other kinds of health care facilities reported 235,159 medication errors that occurred in 2003. Of those, about 20 percent -- or about 43,000 -- involved some kind of automated drug administration system. The group did not have a comparable number from previous reports because it added new categories for computerized medication systems this year, but there was a clear trend of these types of errors increasing, Cousins said.
Errors occurred in all phases of using the systems, including entering incorrect or incomplete information such as patient names, drug doses or lab test results.
The mistakes that occur as a result of these systems tend, however, to be about half as likely to harm patients, the group found.
"What we hope this data will do is identify things that can be designed into the system or designed out of the system," Cousins said.
For example, the data show that many errors occur as a result of the user becoming interrupted or distracted. That suggests the system should be situated in a quiet place where the user can concentrate.
"It shouldn't be in the middle of the patient care unit. There should be an area designated for this -- a quiet area where this can be done in peace," Cousins said.
Other experts said they were not surprised by the findings.
"Technology offers great opportunity to reduce errors, but it's not a panacea," said Kenneth Kizer, who heads the National Quality Forum, a private Washington-based organization trying to improve the quality of health care. "You can't just throw a computerized system in and expect that everything's fixed. It has to be done right. The technology is only as good as the people who use it."
This is an interesting piece as it does not go into any detail as to what the hospitals have implemented in the way of oversight for the systems. While computers are a great tool they should not be relied on solely to administer medications. I would expect that they had some human interaction to double check the dosage that the computer administers, not just for an overdose but for an short dose as well.
It is bad enough having to be in the hospital for any reason. One should not have to worry about whether they will be receiving the proper dose of medication from a human let alone a computer. This is just not acceptable and nothing will be done unless we put our foot down and insist that we receive the best attention and care, after all we are entitled to it.
225K+ people die due to medical neglect each year in the U.S.
Top this all off with hospitals that do not report in a timely fashion the accidental deaths of their patients to the proper authority. You hear about hospitals afraid of law suits and the rising cost of malpractice insurance but we do not see the doctors and hospitals doing anything to prevent malpractice or lawsuits. In fact they seem to be more complacent then ever and accidental injuries and deaths are out of control in our countries healthcare system. How many times have you heard about someone having the wrong limb amputated? Once? Twice? I bet more then that and even one is unacceptable because this can be prevented with a simple $1 worth of YES/NO stickers like my surgeon used. If doctors want to reduce their malpractice insurance and the rate of lawsuits then it is time for them to earn those 6 figure paychecks and do their jobs correctly.
A prescription for safer healthcare
OUR OPINION: WE NEED A NATIONAL REGISTRY ON MEDICAL ERRORS
Hospitals and medical-care providers can do a better job of protecting patients and avoiding injuries during hospital stays. One would be hard pressed not to draw this conclusion, as we did, from reading data in a recent study of healthcare quality in the nation's hospitals.
The report is sobering. It concludes that at least 32,600 patients die each year as a result of avoidable medical errors. We hope that the report spurs hospitals and medical providers not to react defensively, but to rethink patient safety and support calls for a nationwide, mandatory reporting system for medical errors. Only by collecting such data will health officials get a firm grasp of many causes of the hospital errors that kill and injure patients.
Wrong-leg amputation
The fatality estimate by doctors from Johns Hopkins University and the U.S. Agency for Healthcare Research and Quality actually is lower than earlier reports on patient injuries and deaths while under care. Previous estimates placed the number of deaths at between 44,000 to 98,000. But those studies used much smaller samples than the current study, which used a database of 7.45 million hospital discharges. Thus, the Johns Hopkins study is a more-accurate assessment of errors.
Errors can result from a multitude of causes, including administering an incorrect dosage of medication, improper transfusions, surgical mix-ups, mistaken identity, accidental falls, post-operative infections and so forth. For example, one Florida doctor recently amputated the wrong leg of a patient, and another gave an adolescent a fatal dose of medication. None of the medical errors are intentional, and only rarely are they the result of recklessness or negligence. Most, in fact, are caused by faulty systems and processes that cause caregivers to make mistakes or prevent them from catching an error. The doctor who amputated the wrong leg, for example, had been given the information of a different patient.
Malpractice suits
Understandably, doctors and hospitals have grave concerns about reporting such data beyond existing requirements by the state and individual hospitals. They fear that a large database on errors could be used in liability or malpractice lawsuits. That's a valid point.
Since the important thing is to detect and prevent unsafe patterns and behaviors, information about specific doctors and hospitals should be confidential in a national database.
The goal is to identify errors and learn from them. With a national database on these errors, caregivers can develop better procedures, tools and safety protocols for eliminating errors.
No one is immune from making mistakes. But lawmakers and caregivers should do everything in their power to reduce the possibility of harmful errors to patients.
Accidental death in San Francisco
REDWOOD CITY -- After it took administrators at the San Mateo Medical Center a week to inform county leaders of a patient's accidental death in August, a proposed county ordinance would require all major medical errors to be reported to the highest levels of county government within hours of the incident.
Mark Church, president of the Board of Supervisors, proposed an ordinance Wednesday that would mandate public health employees to immediately report any major accidents to their superiors, who must notify the county's top administrator within 24 hours.
The new law is intended to protect employees who report medical errors from retaliation by superiors, but stops short of requiring a victim's family or the public to be notified of the accident.
"We want to create a work environment that promotes the reporting of medical errors, not one that creates fear of reprisals," Church said. "We're not interested in placing blame, but in making sure the same mistakes don't happen again."
On Aug. 11, doctors at the San Mateo Medical Center realized a 41-year-old cancer patient had been given a lethal overdose of a chemotherapy drug. The patient died Aug. 16.
Though hospital staff promptly reported the error to officials, no mention of the incident was made to the county manager, hospital board or supervisors until Aug. 20.
Controversy arose after media reports revealed the hospital did not notify the county coroner of the death and the body was cremated before an autopsy could be performed.
The coroner only learned of the incident after Church announced it in a public meeting. Some in the medical community who feared it would intimidate doctors from admitting their mistakes in the future criticized the move.
Under state law, major errors at any licensed hospital must be reported to the state Department of Health Services for an investigation, but there are no legal requirements that anyone else know about it, including the family of the victim or the public.
Though the proposed ordinance does not explicitly require the county manager to notify the Board of Supervisors of any major incidents at the hospital, Church said that was his intent.
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