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New systems seek to break the medication-error chain
Tuesday, October 16, 2001 By Christopher Snowbeck, Post-Gazette Staff Writer
Could the adverse drug event that killed Kenneth Rigby have been prevented? Rigby, 43, died in December 1997, about three months after doctors implanted a stent to improve blood flow to his right leg.
An occasional series on health care
The surgery went well. But while Rigby was in the hospital, doctors changed a long-standing prescription to treat the Jeanette man's elevated platelet count.
Untreated, the problem would have caused blood clots that might have killed him had they traveled to his brain or heart. But when the doctors switched Rigby from aspirin to a new drug, a different sort of problem emerged -- a disease of the bone marrow marked by a dramatic decrease in platelets. With the disorder, blood fails to clot and platelets clog capillaries, causing organ damage.
Rigby was diagnosed with the bone marrow disorder when he was hospitalized on Oct. 28 and he never returned home.
His wife, Cynthia, won a $1.5 million judgment this past summer against the VA Medical Center in Oakland. A federal judge in Pittsburgh found that doctors had failed to recognize the potential side effect of the new drug and didn't order enough follow-up blood tests that might have caught the problem.
"It's not just that he died," Cynthia Rigby said earlier this month from the Westmoreland County home that the couple designed and built together. "It's that he died this way.
"Anyone put on [the new drug] was supposed to have regular blood work every two weeks. It was quite clear that that was not done."
The toll of mistakes
Ken Rigby is not alone.
Thousand of people suffer from medication errors and adverse drug events every year. Most errors have little potential for harm and most adverse events -- a broader category of problems that can include things such as unknown allergies to drugs -- are not preventable.
But the federal Institute of Medicine published a landmark study in 1999 that found that medication errors kill up to 7,000 Americans annually.
Hospitals here and across the country are working to reduce adverse drug events by using computer technology to prevent hospital mistakes and by sharing information about errors that occur.
Mistakes occur when there is miscommunication between a doctor writing a prescription and a pharmacist filling it; pills with similar names or appearance are mistaken for one another; the right pill is given to the wrong patient or patients misunderstand how and when to take their medicines. And, as in Ken Rigby's case, some adverse drug events stem from improper follow-up.
The Institute of Medicine's report fixed blame more on hospital systems than individuals.
The Institute of Safe Medicine Practices, based in Philadelphia, has called on hospitals to take the costly step of computerizing all prescription orders.
In the simplest sense, computerized prescriptions eliminate errors that stem from misinterpreted handwriting and abbreviations.
Computers also can maintain accurate lists of medicines and screen for adverse interactions, as well as warn doctors about potential overdoses, allergies and a patient's underlying medical conditions.
"The main intervention would be computerized prescription order entry, where there's a computer in patient care areas where orders are entered," said Hedy Cohen, vice president of the Philadelphia institute.
The system could warn health-care workers if an improper drug dose was given to a patient with kidney disease, for example, based on blood indicators that measure kidney function.
State of the art
Locally, the VA Pittsburgh Healthcare System has one of the most advanced computerized prescription ordering systems, established in 1999 as part of a national VA initiative. The system gives doctors a patient's pertinent lab results before ordering medications. It also alerts doctors when it's time to reorder drugs. All inpatient prescriptions are written on the system.
More recently, the local VA installed a bar code medication administration system, in which patients and drugs dispensed in the hospital are given a bar code.
When a doctor types in a medication order, it goes to the pharmacy where the pharmacist sees it, makes sure it's a good clinical decision and sends it back to the hospital floor tagged with a bar code.
"When the medicine goes to the patient, the nurse scans the medicine bar code and then the bar code on the patient's wristband," said Michael Moreland, director and chief executive officer of the VA Pittsburgh system. "Then the computer says, 'yes, this is the right medicine for the patient at the right time.' "
Ohio Valley General Hospital in Kennedy started using a similar system last month in its 26-bed intensive care/step-down unit. When nurses deliver medicines to patient rooms, they carry wireless, hand-held scanners.
Using the machine can slow a nurse down, but its value is clearly proved when a busy nurse realizes that he or she has brought a medicine to the wrong patient, said Peg Spisak, director of quality and risk management at Ohio Valley.
But as some grocery store shoppers know first-hand, bar coding is not always fail-safe. To make the systems work best, drug makers need to apply bar codes down to the unit of dose given to a patient, said Dr. John Combes, senior medical advisor of the Hospital and Healthsystem Association of Pennsylvania.
Combes is a member of the National Coordinating Council for Medication Error Reporting and Prevention, which defines medication errors and how to grade their severity. It has asked manufacturers to improve bar coding because hospitals now must use commercial products or systems they've created to put bar codes on individual medicine packages.
"Adding that step can open yourself to an error," Combes said.
Improving reporting
In the Pittsburgh area, 10 hospitals are contributing information about errors to a database called MedMARx, an anonymous, confidential, Internet-based system for reporting errors. Hospitals pay around $5,000 per year for access to the system, which is operated by U.S. Pharmacopeia, a Maryland nonprofit group that sets quality standards for medicines.
The database can provide hospitals with a look at medication errors made in their own institutions -- or among the 500 hospitals that feed information to the database -- to help them prevent future mistakes.
"The idea is to use this for risk prevention rather than risk management," said Diane Cousins, vice president for practitioner and product experience at U.S. Pharmacopeia.
The Pittsburgh Regional Healthcare Initiative selected MedMARx as the common platform to which all hospitals in the region could confidentially report errors.
Mercy Hospital has been one of the first to report errors to the system. Dr. JoAnn Narduzzi, executive vice president of medical affairs at Mercy, said hospitals haven't been in the practice of sharing information about the lessons they learned.
Narduzzi said that Monongahela Valley Hospital recently brought to PRHI an example of a how pharmacists were catching prescriptions written with unclear abbreviations. A synthetic thyroid drug can be prescribed in 50 microgram doses, but when written by hand, the Latin abbreviation for micrograms -- g -- can look like "mg" for milligrams. If 50 milligrams of the drug Synthroid are dispensed instead of 50 micrograms, patients would be taking the medicine at 1,000 times its proper strength.
It's great that Mon Valley recognized the problem and instituted a policy requiring the abbreviation "mcgs" be used for Synthroid. Unfortunately, Mercy had instituted the same policy in the late 1980s.
"If we had had an opportunity for talking to one another back then, we could have shared that information," she said.
Key to getting information about errors is developing a non-punitive culture in hospitals, so that employees believe that they will be contributing to a quality improvement project -- not just incriminating themselves or their colleagues.
Thanks in large part to a phone hot line Mercy set up to make it easier for employees to report incidents, reports have doubled since April. That doesn't mean the number of problems has increased, Narduzzi said. "A majority of our medication errors were not being reported."
Collecting information about errors to drive quality improvement is not unique to Pittsburgh.
The hospital association is working with the state Department of Health to increase reporting of serious medication errors to the state, as required by law. In the past, that system has generated few reports.
KePRO, a Harrisburg organization hired by the federal government to provide quality improvement products to Medicare patients, has created a computer system for reporting medication errors that has been installed in nearly 10 hospitals across the state.
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