2.15.2008

Preventing Medication Errors Takes More Than Technology

I wrote recently about research by the Philadelphia Inquirer into how many hospital patients are actually harmed by serious, avoidable medical errors. Now new research looks at how many patients suffer from a particular type of error – a mistake in medication.

According to a
report in the Boston Globe, a new study released by two non-profit groups found that one in every 10 patients admitted to six community hospitals in Massachusetts suffered “serious and avoidable” medication mistakes.

The researchers who prepared the report looked at 4,200 randomly selected patient medical charts at the six hospitals, covering stays from January 2005 to August 2006.

A mistake was defined as a patient being given a drug even though the medical records indicated it might trigger an allergic reaction or exacerbate a medical condition.

Medication errors were counted only when patients suffered serious reactions, including going into shock or suffering kidney failure. In nearly every instance, the patients remained in the hospital longer to recover from the mistake. Nobody died from any of the mistakes, researchers said.

This kind of information is valuable because it show the problems that can result from flawed processes and the benefits that can be achieved from improving them.

However, I am concerned that everyone seems to think the answer to the problem is technology. The article says none of the community hospitals has a computerized physician order entry system,


which requires doctors to type into a central database every medical order, including prescriptions, diagnostic tests, and blood work. The doctors' orders are matched against the patient's medical history, triggering red flags to prevent problems related to drug allergies, overdoses, and dangerous interactions with other drugs…

After this system was put in place at Brigham and Women's Hospital in 1995, preventable medication errors declined by 55 percent over the next two years.

Don’t get me wrong, I have nothing against technology. And if this type of system seriously reduces medical errors, great.

What concerns me is whether anyone is really examining the causes of the medication errors, rather than just assuming that a computerized system will take care of everything.

Why were errors at Brigham and Women’s Hospital reduced by only 55 percent? Clearly, the computerized system didn’t eliminate all errors. There are probably process flaws still causing errors, and those flaws weren’t addressed by computerization. But they probably could be addressed by a systematic lean approach that maps processes, identifies sources of problems, then uses mistake-proofing and/or other tools to solve them.

More technology is needed in hospitals. But it’s not enough.

1 comments:

Dean Bliss said...

You're right, Ralph - the process issues are there, and need to be addressed. Through organizations such as the Institute for Healthcare Improvement, healthcare organizations are tackling this issue, which is more complex than it may appear on the surface. The goal is to eliminate this type of error, which will take a combination of process improvement and technology to bring us as close to perfection as we can get.