An adverse outcome from a medication error can undermine years spent building a solid reputation for healthcare prowess. Just ask Dana-Farber Cancer Institute.
The world-renowned Boston facility is "in the midst of intensive self-examination" following a cancer-drug overdose that killed a noted local health columnist.
That statement was issued after reporters put Dana-Farber under the microscope and the Joint Commission on Accreditation of Healthcare Organizations put it on probation (April 24, p. 16). But a coalition of pharmacists and clinicians emphasized last week that the same critique should be going on industrywide.
Just a few weeks before Dana-Farber's mistakes were made public, the American Society of Health-system Pharmacists published the proceedings of a conference that assembled nearly 100 healthcare professionals last fall to analyze what causes serious medication errors.
The conference recognized that about one out of every 100 drug dosages in a hospital is in error and that a systematic approach to reducing errors must be interdisciplinary-physicians, pharmacists, nurses and patients working together, said William Zellmer, the ASHP's vice president for professional and government affairs.
The ASHP first issued interdisciplinary guidelines aimed at preventing medication errors in 1993 (See chart). The conference, co-sponsored by the American Medical Association and the American Nurses Association, further refined that collaborative approach, Zellmer said.
The ASHP has warned for several years that the hospital process set up to prescribe, fill, administer and monitor medications should be carefully examined. "There are so many opportunities for errors, and any one of them can be a fatal mistake," he said.
Playing a position.
If health professionals are focused only on their own job instead of the overall goal of error-free drug dispensing, it can create a weakness at points in the system where responsibility is passed from one department to another-like the "seam" between zones covered by different players in a football defense.
"We seem to be stuck in our own professions when what the public needs is for us to function jointly," said Barbara Redman, professor of nursing at Johns Hopkins University in Baltimore.
Besides the profession-centric problem, there's the weakness of assuming that medications are being handled adequately by others, said ASHP spokeswoman Rebecca Wilfinger. She said clinicians should act as if they're first to check the medication.
"Everyone has to pretend to be that new set of eyes," she said.
According to news reports, Boston Globe columnist Betsy Lehman was given four times the maximum dose of a highly toxic cancer-fighting drug and a fourfold overdose of another drug for the side effects. At least a dozen physicians, pharmacists and nurses continued to overlook the error for four days. Meanwhile, Lehman was having severe drug reactions, suffering from an irregular heartbeat and registering abnormal lab tests. Dana-Farber took full responsibility for the error, which caused heart failure.
Working in unison.
In its April 14 statement, Dana-Farber said that it "has begun initiating improvements resulting from our own systems review" and that it was "working diligently to eliminate any issues raised by the Joint Commission and other agencies."
The JCAHO revised its standards for medication use in 1994 to require leadership involvement in a systematic approach to prescribing, dispensing, administering and monitoring, said Deborah Nadzam, director of indicator measurement for the Joint Commission.
The standards recognize "the potential for breakdown" if each department is interested only in its part of the medication process, Nadzam said. Surveyors now look for evidence that employees are alert at "the handoff" between disciplines.
If the prescriber orders the wrong dose, for example, the pharmacist should catch it, she said. If not, then the nurse should be trained to catch the error when administering it. Hospitals also should not overlook patient involvement, she added. Educating patients on their medication can be an important preventive measure.
"Sometimes it is the patient who says, `I got this medication as a pill four hours ago-why am I getting a shot now?'*" Nadzam said.
The interdisciplinary conference published recommendations in the Feb. 15 issue of the American Journal of Health-Systemfor each of the main groups involved in error prevention:
Pharmacists. Their role should be redefined to make them on-site members of the patient-care team and immediate resources about drug indications, interactions and administration.
Physicians. Prescribers should consult more frequently with pharmacists to stay on top of new drug therapies and use them appropriately. More physicians should enter orders by computer to eliminate errors from illegible writing, spoken orders and wrong abbreviations.
Nurses. As the employees chiefly responsible for administering drugs, nurses should have greater participation in error-prevention strategies, and executives should understand demands on nurses' time.
Consumers. Patients should be the final checkpoint, scrutinizing labels and directions, asking questions, and alerting clinicians about allergies and concurrent medications.
Guidelines for preventing medication errors in hospitals
Established in 1993, the procedures cover each medical discipline involved in the process. Some examples:
Pharmacists should review and verify all prescription orders.
Drugs should be distributed by the pharmacy in individual doses rather than in concentrated form, which must be diluted.
Physicians with poor handwriting should type or print orders.
Dictated prescriptions should be read back to the physician for accuracy.
Nurses should verify medication against the original order.
Patient identity should be verified before prescription is given.
Source: American Society of Health-system Pharmacists