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Getting it write Changing the low-tech way prescriptions and records are written could reduce outpatient medication errors Tuesday, June 26, 2001 By Christopher Snowbeck, Post-Gazette Staff Writer
Shirley Romansky doesn't remember exactly what happened, but on a March night in 1999 she fell twice while trying to walk from her living room to the kitchen.
The 67-year-old woman, who lives alone, was able to crawl about 30 feet to her bathroom where she fell again. She eventually dragged herself across her Latrobe apartment to her bed, where she was awakened by her daughter's phone call the next morning.
Romansky, who has vision problems and lacks sensation in her feet due to diabetes, had made some confused comments when family members made their usual telephone checks on previous days.
But the falls made it clear that she was suffering from an acute health problem, one that her doctors later determined was caused when a pharmacist filled a prescription with the wrong drug.
Romansky's story is one example of the thousands of medication errors that could be prevented each year by improving communication between doctors and pharmacists.
In 1999, the federal Institute of Medicine estimated that as many as 98,000 hospital patients die each year because of medical errors, with as many as 7,000 of those deaths stemming from medication mistakes. While the scope of the medication errors problem outside hospitals is not clearly defined, the IOM noted that outpatients filled nearly 2.5 billion prescriptions in 1998 and the number of problem prescriptions seems to be growing at a faster rate than those in the hospitals.
Worst of all, the problem outside hospitals could be more difficult to solve.
"A significant number of patients end up in the emergency room because they've followed their doctors' orders," said Dr. Russell Ricci, general manager of IBM global healthcare.
That was true for Romansky, who is now 70. She was admitted to Latrobe Area Hospital on March 17, 1999 for an overdose of amitriptyline, an antidepressant that also goes by the name Elavil.
A few days earlier, Romansky's pharmacist had given her the Elavil pills and instructions to take 100 milligrams three times daily. The problem was her doctor's prescription had been for Elmiron, intended to treat a urinary tract disease, not Elavil.
Romansky also had a separate prescription to take Elavil at 25 mg per day for pain, but instead she left the pharmacy that day with two Elavil prescriptions that, combined, had her taking 325 mg daily -- 13 times her usual dosage. Because of her eye problems, Romansky wasn't able to catch the mistake.
"The pharmacist told me, 'Either the doctor wrote it wrong or we read it wrong,'" Judy Zlotkowski, Romansky's daughter, wrote to state investigators about the incident.
The digital solution
Called everything from Palm Pilots to Pocket PCs, hand-held computers could play a key role in improving communication by eliminating handwriting in prescriptions, which can be misread due to bad penmanship, archaic abbreviations and medicines that have similar names.
Electronic systems also offer improved safety by giving doctors immediate information about whether a drug will interact badly with another of the patient's medicines or health problems.
The Institute for Safe Medication Practices in Huntingdon Valley, Pa., has called for an end to handwritten prescriptions by 2003 and local health plans are creating programs that promote this goal. But Hedy Cohen, vice president of the group, says reaching it won't be easy.
"Change is always difficult," she said. "The physicians will have to begin getting comfortable using hand-held devices. They also have to go out and look at them and evaluate them, and I think a lot of physicians don't feel expert in computers."
Outpatients often receive numerous prescriptions from numerous doctors and can have them filled at different pharmacies. So, in many cases, no one professional has a complete picture of a patient's medicines.
Add to this the pace of drug discovery, and the situation seems a prescription for confusion. The number of drugs on the market grew 500 percent in the 1990s; by 1999, pharmaceuticals were marketed by more than 17,000 trade and generic names in North America.
The National Wholesale Druggists' Association reported that nearly 2.5 billion prescriptions were dispensed by U.S. pharmacies in 1998. Estimates suggest the number will reach 4 billion by the year 2005 -- this at a time when there is a shortage of pharmacists.
Drug names themselves can lead to problems. Celebrex, Celexa and Cerebyx, for example, are names that look alike but treat, respectively, arthritis, depression and epilepsy. Two drugs share the same pronunciation: Lamicel and Lamisil. The first is a cervical dilator, the latter is an antifungal agent.
Misreading a decimal can result in a 10-fold overdose. An order marked as "qd" -- doctor's shorthand that means "once a day" -- might be read as "qid," meaning take four times per day. Pharmacists end up making millions of calls to physician offices each year to clarify drug orders, but not all mistakes are caught.
An Illinois company called Allscripts was the first to develop a hand-held system whereby physicians can write a prescription on a pocket computer and send the typed prescription through the Internet or fax to a pharmacy. Other companies such as iScribe, ePhysician and ParkStone now make similar devices. This spring, IBM, Pfizer and Microsoft announced an initiative to develop health-care computer systems, including one that tackles outpatient medication errors.
Aetna U.S. Healthcare has a contract with Allscripts. The health plan provides the computer company with its formulary, a list of drugs for which the health plan covers most of the costs. Doctors thus can be told immediately whether the drug being prescribed is in the formulary. That's important because non-covered medicine could mean money out of the patient's and/or the doctor's wallet.
Ninety-two doctors in Western Pennsylvania use Allscripts, which also lets doctors dispense drugs directly to their patients from a computer-controlled cabinet.
Script Fast, a company based in Mechanicsburg, allows for the electronic transmission of prescriptions, but sends them from a regular computer in a doctor's office. That means office personnel who already are responsible for phoning in prescriptions now communicate through the computer, said Curtis Hess, vice president of the company.
Highmark Blue Cross Blue Shield is adding a prescription writing feature to a computerized billing system called NaviMedix, which is already in 735 Western Pennsylvania doctor offices. Since April 1, the system has allowed 30 doctors in five offices to send 55 new and renewal prescriptions to mail-order pharmacies.
The system also lets the offices make printed prescriptions that can be taken to retail pharmacies. Eventually, retail pharmacies will be able to receive prescriptions through the Internet.
Warning the doctors
Short of the patients themselves, insurance companies have the most complete set of information about patient medicines, so the Aetna and Highmark programs have the potential to alert doctors and pharmacists to potential adverse drug interactions.
The Highmark program, for example, will warn that a patient taking iron salts, prescribed by one doctor to treat anemia, could have trouble absorbing Cipro or a similar antibiotic that another doctor might consider prescribing for an infection. With this knowledge, a doctor could recommend that the patient take the medications at least 2 hours apart to decrease the adverse interaction.
Twenty-one doctors working with the UPMC Health Plan last winter started using a program called Pinpoint, which runs on a desktop computer and lets physicians look at all of their patients' medicines. The program includes a check for adverse interactions.
"We print [the medicine list] out today for our patients tomorrow," said Dr. Grant Shevchik, a family doctor in Murrysville. "When you come in, I see what you're getting, I see you may be getting medications that we didn't prescribe and I also see if you didn't get some prescriptions refilled -- that's one of the most interesting features."
Pinpoint doesn't have an electronic prescription component, but Shevchik says his practice has an electronic medical record that prints out prescriptions.
UPMC St. Margaret is helping family practice residents prepare for the electronic future by giving them hand-held computers. Residents use the machines to look up medical references, calculate medicine dosages and keep their schedules. If residents pass a series of proficiency tests, they are allowed to take the machines with them when they go into practice.
All of this sounds good, but Michael Hornick, a pharmacist in both Moon and Midland, Beaver County, says electronic transfer of prescriptions won't prevent every mistake. The investments in machinery should not displace investments in people, since the discovery of some problems comes from talking with the patient.
"One of the big source of errors is patient noncompliance and you don't get patient compliance by encouraging the McDonald's practice of medicine -- a centrally driven, centrally planned system whereby health care is delivered just like you get a hamburger," Hornick said.
But Hornick welcomes attention to the problem, which health care providers know can land them in hot water.
In October 1999, for example, a Texas cardiologist was ordered to pay $225,000 to the family of a patient who died after receiving the drug Plendil instead of Isordil. The pharmacist could not read the prescription, according to the Institute for Safe Medicine Practices.
The Physician Insurers Association of America reported that medication errors related to misinterpreted physicians' prescriptions were the second-most prevalent and expensive claim listed on 90,000 malpractice claims filed over a recent seven-year period.
Shirley Romansky, the Latrobe woman who suffered a medication error, spent two days in the hospital because of the error. Two years late, she seems more tentative than she used to be and has suffered more falls, her daughter Judy Zlotkowski says. But there haven't been any health problems that can be clearly linked to the medication error.
Zlotkowski lodged a complaint with the state Board of Pharmacy about the incident. Pharmacist Tracy G. Rosky and Mossos Pharmacy of Latrobe agreed that the wrong medicine was dispensed and, short of admitting guilt, paid $700 in fines.
To Zlotkowski, the civil penalty doesn't match Romansky's $4,627.08 hospital bill, let alone her mother's pain.
"My mother was in the hospital for two days. She had a bump on her head, her arm was in a sling because she bruised her shoulder and they did a CT scan on her," she said. "She has no memory of seven days of her life."
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