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Preventing Medication Errors (2007)

Chapter: 5 Action Agenda for Health Care Organizations

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Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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5
Action Agenda for Health Care Organizations

CHAPTER SUMMARY

Health care providers need to develop safer medication-use systems. This chapter presents the committee’s recommendation for systemic changes in three settings—inpatient, nursing home, and outpatient—and in care transitions. Recognizing that systemic change takes time, the committee proposes ways in which individual physicians, pharmacists, and nurses can improve medication safety in the short term. In addition, health care providers must acknowledge that the work of making medication use safer is never finished. Thus the chapter provides guidance on ways to monitor for medication errors.

This chapter presents the committee’s recommendation for systemic changes aimed at improving the safety of medication use. These recommendations are directed at providers in three settings—inpatient, nursing home, and outpatient—as well as in care transitions, which can be especially problematic with respect to the risk of medication errors. In formulating its recommendations, the committee bore in mind the diversity of each of these settings; for example, the outpatient setting encompasses ambulatory care, home care, community pharmacies, care in schools, and assisted living. Overall, the committee believes patients should be involved in their medication-related care in all settings, with the extent of their autonomy being determined by their preferences and capacity.

The committee’s recommendation is intended to apply to all of the

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

above settings, although the way it is implemented will vary by setting, as will the medication-use systems and the errors and adverse drug events (ADEs) that may occur. In the inpatient setting, for example, major safety issues include medication selection and administration (Bates et al., 1995a). By contrast, in nursing homes and the outpatient setting, monitoring is especially important (Gandhi et al., 2003; Gurwitz et al., 2000, 2003). In all settings, access to patient-specific and reference information is central to delivering safe medication-related care.

Actions identified by the committee that can be taken to improve medication safety by individual prescribers are summarized in Box 5-1, by individual pharmacists in Box 5-2, and by individual nurses in Box 5-3. The committee’s recommendation for systemic changes across health care settings is then presented. The remainder of the chapter provides a detailed discussion of the specifics of this recommendation.

Many of the actions for providers listed in Boxes 5-1 to 5-3 are recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality Forum (NQF). Since 2003, JCAHO has set annual National Patient Safety Goals (JCAHO, 2005) and included a survey of compliance with the requirements as part of the accreditation process. Many of the National Patient Safety Goals relate to medications (see Box 5-4). The Agency for Healthcare Research and Quality (AHRQ) requested that the NQF use an expert consensus process to define a list of best safety practices. The resulting NQF report, Safe Practices for Better Healthcare, listed 30 practices that should be universally adopted in applicable care settings, 13 of which involve the use of medications (see Box 5-5), and another 27 practices (15 of which are medication-related) that should receive high priority for additional research (NQF, 2003).

A number of additional key points should be emphasized. First, having a safety culture is pivotal to improving medication safety. To institute a safety culture, senior management must devote adequate attention to safety and provide sufficient resources to quality improvement and safety teams. Senior management must also authorize resources to invest in technologies that have been demonstrated to be effective but are not yet widely implemented in most organizations, such as computerized provider order entry (CPOE) and electronic health records. It has become increasingly clear that the introduction of any of these technologies requires close attention to business processes and ongoing maintenance. A number of studies have shown that these tools can have unintended and adverse consequences, and that avoiding such consequences requires addressing business and cultural issues.

Improvements in the safe use of medications need to be implemented within the context of an overall quality improvement program, specifically

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

BOX 5-1

Improving Medication Safety: Actions for Prescribers

  • Reconcile medications at transition points, e.g., admission, discharge, transfer. (All)

  • Make routine the reconciliation of medication changes with the pharmacy record. (NH/AL, Out)

  • Avoid verbal orders except in urgent situations and emergencies. (In)

  • Be aware of other medications the patient is taking when prescribing. (NH/AL)

  • Keep an accurate medication list (including over-the-counter and complementary and alternative medications). (Out)

  • Ask patients to bring their medications in periodically. (Out)

  • Ask about allergies when prescribing a new medication. (Out)

  • Inform the patient of indications for all medications. (Out)

  • Ask regularly whether patients are taking their medications, including as-needed drugs, as nonadherence may signal issues other than knowledge deficits, practical barriers, or attitudinal factors. (Out)

  • Ask the primary pharmacy about the patient’s refill history. (Out)

  • Consider that new complaints may represent side effects of medications. (NH/AL)

  • Explain common or significant side effects when prescribing. (Out)

  • Ask regularly about side effects or adverse drug events (ADEs). (All)

  • Prescribe electronically when possible. (All)

  • Use readback with verbal orders when feasible. (All)

  • Avoid abbreviations. (All)

  • Include patient age and weight when applicable. (All)

  • Work as a team with pharmacists and nurses. (In)

  • Work as a team with consultant pharmacists and nurses. (NH/AL)

  • Work as team with the primary pharmacist and nurses. (Out)

  • Adhere to Class I clinical indications and guidelines. (All)

  • Use special caution with high-risk medications (All), especially warfarin. (NH/AL)

  • Exercise particular caution in high-risk situations—when stressed, sleep-deprived, angry, or supervising inexperienced personnel. (All)

  • Consult electronic or other reference sources for questions. (All)

  • Report errors and ADEs. (All)

  • Include medications when transferring patients between providers. (In)

  • Standardize and improve transfers between covering physicians and other providers. (NH/AL)

  • Standardize communication about prescriptions within the practice; standardize and improve handoffs to the primary pharmacist. (Out)

  • Actively monitor the patient for response to medication therapy, and use validated instruments when possible. (Out)

  • Minimize the use of free samples; when dispensing free samples, apply standards similar to those a pharmacy would use. (Out)

NOTE: All = all prescribers; In = inpatient prescriber; NH/AL = nursing home/assisted living prescriber; Out = outpatient prescriber.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

BOX 5-2

Improving Medication Safety: Actions for Individual Pharmacists

  • Monitor the medication safety literature and other resources regularly for information related to medication errors, and take action to ensure that similar errors will be avoided in the local practice setting. (Amb and Hosp)

  • Develop, implement, and follow a medication error avoidance plan. (Amb)

  • As part of this plan, establish a routine procedure for double-checking filled prescriptions waiting to be picked up and verifying the accurate entry of data on new prescriptions into computer systems. (Amb)

  • Monitor error frequencies, and correct system problems associated with errors. (Amb and Hosp)

  • Use the show-and-tell counseling method to detect and correct dispensing errors; this should include verification of patient identity. (Amb)

  • Educate consumers regarding error prevention techniques and resources (e.g., websites such as http://www.ismp.org, http://www.safemedication.com, and http://www.ahrq.gov). (Amb)

  • Pharmacy managers designate a medication safety officer with responsibility for improving the safety of prescription filling processes. (Amb)

  • Advocate for a medication safety officer with responsibility for improving medication safety throughout the hospital. (Hosp)

  • Create a safe work environment by optimizing lighting levels, using a magnifying lens or resizable scanned prescription for viewing prescription slips, minimizing distractions, and arranging drug storage areas to call attention to drugs with a high potential for errors leading to patient harm. (Amb)

  • Create a safe work environment by optimizing lighting levels and minimizing distractions and interruptions. (Hosp)

  • Advocate for a statewide medication safety coalition, to include the state board of pharmacy, pharmacy organizations, practitioners, and consumers. (Amb and Hosp)

  • Report errors and near misses to both internal and external medication error reporting programs or systems to help others learn how to avoid similar problems. (Amb and Hosp)

  • Request resources needed to promote accurate prescription dispensing (clinical decision support, bar code verification technology, time for counseling patients). (Amb)

  • Be assertive in requesting resources needed to promote accurate medication processing and dispensing (clinical decision support, bar code verification technology). (Hosp)

  • Actively pursue a tiered system of clinical alerts that can facilitate better response to serious medication safety issues (e.g., suppress trivial warnings and retain those with a high probability of patient risk). (Amb and Hosp)

  • Evaluate and continuously monitor new technologies (e.g., automated prescription filling machines) regarding the risk of introducing medication errors. (Amb)

  • Evaluate and continuously monitor new technologies (e.g., infusion pumps, automated medication dispensing machines) regarding the risk of introducing medication errors. (Hosp)

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×
  • Regularly make targeted follow-up calls to patients (e.g., those with asthma, chronic pain, hypertension) to assess how they are faring with new medications, learn about any side effects or potential ADEs, and ensure that medications are being taken properly. (Amb)

  • Work with nurses to make regular targeted follow-up calls to discharged patients (e.g., those with asthma, chronic pain, hypertension) or use mailed questionnaires to assess how these patients are faring with prescribed medications, learn about any side effects or potential ADEs, ensure that medications are being taken properly, and answer any questions patients may have.

NOTE: Amb = ambulatory care pharmacist; Hosp = hospital pharmacist.

BOX 5-3

Improving Medication Safety: Actions for Nurses

  • Establish safe work environments for medication preparation, administration, and documentation; for instance, reduce distractions and provide appropriate lighting.

  • Maintain a culture of rigorous commitment to principles of safety in medication administration (for instance, the five rights of medication safety and crosschecks with colleagues, where appropriate).

  • Remove barriers to and facilitate the involvement of patient surrogates in checking the administration and monitoring the effects of medications wherever and whenever they are administered.

  • Foster a commitment to patients’ rights as coproducers of their care.

  • Develop aids for patient (or surrogate) self-management support.

  • Enhance communication skills and team training so as to be prepared and confident in questioning medication orders and evaluating patient responses to drugs.

  • Actively advocate for the development, testing, and safe implementation of electronic health records.

  • Work to improve systems that address the most common near misses in the work environment.

  • Actively participate in or lead evaluations of the efficacy of new safety systems and technology.

  • Contribute to the development and implementation of error reporting systems, and support a culture that values accurate reporting of medication errors.

BOX 5-4

National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations Relating to Medication Use

Goal 1: Improve the accuracy of patient identification

1A. Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products, taking blood samples

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

and other specimens for clinical testing, or providing any other treatments or procedures.

1B. Prior to the start of any invasive procedure, conduct a final verification process to confirm the correct patient, procedure, site, and availability of appropriate documents. This verification process uses active—not passive—communication techniques.

Goal 2: Improve the effectiveness of communication among caregivers

2A. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.

2B. Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization.

2C. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

2E. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Goal 3: Improve the safety of using medications

3B. Standardize and limit the number of drug concentrations available in the organization.

3C. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.

3D. Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.

Goal 8: Accurately and completely reconcile medications across the continuum of care

8A. Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

8B. A complete list of the patient’s medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

Goal 13: Encourage the active involvement of patients and their families in the patient’s care as a patient safety strategy

Define and communicate the means for patients to report concerns about safety and encourage them to do so.

SOURCE: JCAHO, 2005.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

BOX 5-5

The National Quality Forum’s Safe Practices for Better Health Care

Among the 30 safe practices identified by the NQF consensus report, the following 13 relate to medication use:

1. Create a health care culture of safety.

3. Specify an explicit protocol to be used to ensure an adequate level of nursing based on the institution’s usual patient mix and the experience and training of its nursing staff.

5. Pharmacists should actively participate in the medication-use process, including at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

6. Verbal orders should be recorded whenever possible and read back to the prescriber—i.e., a health care provider receiving a verbal order should read or repeat back the information that the prescriber conveys in order to verify the accuracy of what was heard.

7. Use only standardized abbreviations and dose designations.

8. Patient care summaries or other similar records should not be prepared from memory.

9. Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient’s current health care providers who need that information to provide care.

12. Implement a computerized prescriber order entry system.

25. Decontaminate hands with either a hygienic hand rub or by washing with disinfectant soap prior to and after direct contact with the patient or objects immediately around the patient.

27. Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction, and noise.

28. Standardize the methods for labeling, packaging, and storing medications.

29. Identify all “high alert” drugs (e.g., intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and antithrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics and opiates.

30. Dispense medications in unit-dose or, when appropriate, unit-of-use form, whenever possible.

SOURCE: NQF, 2003.

within the clinical unit—a small group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients (Mohr and Batalden, 2002). Research on highly effective clinical units has indicated that they share a number of characteristics (Mohr and Batalden, 2002). Such units (1) integrate information within the care deliv-

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

ery process (often with technology playing a key role); (2) monitor processes and outcomes routinely to assess the quality of care delivered; (3) provide care through multidisciplinary teams sharing information among providers and patients; (4) make resources available for quality improvement, including staff training; and (5) work within a larger management environment that is supportive of quality improvement. The application of these ideas at LDS Hospital, Salt Lake City, Utah, led to reduced ADE rates and postoperative deep wound and organ space infection rates (IOM, 2004). Similarly, application of these principles in intensive care units (ICUs) has led to reductions in medication errors in patient transfer orders using medication reconciliation (Pronovost et al., 2003a) and to reduced ICU lengths of stay using a one-page daily goals form to improve the effectiveness of communication among the care team (Pronovost et al., 2003b).

The committee also believes that all organizations in all settings need to monitor rates of medication errors and ADEs more effectively. Most organizations have focused solely on spontaneous reporting, which is necessary but not sufficient. While spontaneous reporting has and will continue to produce highly valuable information, especially at the regional and national levels, internal improvement at the organizational level requires ongoing measurement of meaningful rates. Observation is valuable for assessing administration. In addition, it will increasingly be possible to detect errors and ADEs through computerized monitoring, and such monitoring produces much more reliable information about rates of errors and ADEs in the patient population than does spontaneous reporting.

Recommendation 3: All health care organizations should immediately make complete patient-information and decision-support tools available to clinicians and patients. Health care systems should capture information on medication safety and use this information to improve the safety of their care delivery systems. Health care organizations should implement the appropriate systems to enable providers to:

  • Have access to comprehensive reference information concerning medications and related health data.

  • Communicate patient-specific medication-related information in an interoperable format.

  • Assess the safety of medication use through active monitoring and use these monitoring data to inform the implementation of prevention strategies.

  • Write prescriptions electronically by 2010. Also by 2010, all pharmacies should be able to receive prescriptions electronically.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

By 2008, all prescribers should have plans in place to implement electronic prescribing.

  • Subject prescriptions to evidence-based, current clinical decision support.

  • Have the appropriate competencies for each step of the medication-use process.

  • Make effective use of well-designed technologies, which will vary by setting.

ACCESS TO POINT-OF-CARE REFERENCE INFORMATION

Providers should have access to comprehensive reference information concerning medications and related health data.

A number of studies have examined the information needs of practicing clinicians (Covell et al., 1985; Gorman, 1995; Gorman and Helfand, 1995; Ely et al., 1999, 2005; Shablinsky et al., 1999). These studies have found that patient care generates a large number of clinical questions, regardless of the provider’s specialty. Covell and colleagues (1985) found that internal medicine physicians, both generalists and primary care, generated approximately two clinical questions for every three patients seen. Gorman (1995) found that physicians asked slightly over one question per two patients (Gorman, 1995), while Barrie and Ward (1997) found they asked just over one question per five patients. Much less is known about the information needs of providers other than physicians, but it is reasonable to assume that nurses, pharmacists, and others have frequent needs for clinical information. It should be noted that research indicates nurses prefer to gain knowledge from personal experience and interactions with coworkers and patients rather than from journal articles, textbooks, or research resources (Thompson et al., 2001; Estabrooks et al., 2005).

Most investigators have found that the majority of the questions raised by clinicians during patient care go unanswered1 (Covell et al., 1985; Gorman, 1995; Ely et al., 1999). Moreover, when clinicians do seek further information, they spend, on average, only 2 minutes doing so. By contrast, one study found that trained librarians took an average of more than 10 minutes to find answers to well-formulated clinical questions all focused on a single illness (Giuse et al., 1994). The clinical impacts of the decision not

1

Examples related to medications are: “This patient is already on a maximal dose of the most potent statin. Which secondary drug—niacin, ezetimibe, or a fibrate—has the greatest impact on stroke and myocardial infarction?” and “This patient is not doing well on valproic acid for controlling bipolar symptoms. Would it be better to add an atypical antipsychotic or switch to another primary medication?”

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

to seek further information have not been rigorously evaluated, though it is reasonable to assume that such impacts do occur.

Remaining current, even in highly focused areas, has become extremely difficult for clinicians (Giuse et al., 1994). Thirty years ago, it was estimated that there were 1 million facts in the core body of general knowledge in internal medicine (Pauker et al., 1976). This number has likely increased significantly since that time. Nonetheless, most clinicians still rely primarily on memory and clinical experience. Despite the widespread availability of data through the World Wide Web, little improvement in knowledge management has been documented over the past decade (Covell et al., 1985; Gorman, 1995; Ely et al., 2005). Even when clinicians have access to electronic databases, the process of seeking information from these sources is typically so time-consuming as to be impractical in many patient care settings (Alper et al., 2001). With the continuing expansion of medical information, this situation is unlikely to improve without new approaches to knowledge management (Smith, 1996).

The decision to initiate a clinical intervention requires the synthesis of a wide array of data, resulting at a minimum in a probable diagnosis and logical therapeutic options. Medications are the most common options offered (Woodwell and Cherry, 2004). The continuing availability of new pharmacotherapeutic options creates an ongoing need for new knowledge to ensure safe prescribing. Appropriate and safe pharmacotherapy demands not only knowledge of the medication itself, but also appropriate decision making prior to the start of therapy, an understanding of how the medication may interact with coexisting illnesses and medications, and knowledge of requirements for monitoring for success and side effects. Dealing with all these variables requires an extraordinary degree of information synthesis (Smith, 1996). Not surprisingly, then, practicing clinicians indicate a need for highly synthesized and abridged information (Grandage et al., 2002).

Access to the Clinical Knowledge Base

Given that the knowledge base and decision processes are often unique to a particular care setting, clinicians require knowledge gathered from studies conducted in appropriate settings with appropriate patient populations and in a particular stage of the care process (Oxman et al., 1993). The concept of just-in-time information, a given in many businesses, has developed in medicine over the past decade in response to this challenge (Ebell, 1999; Ely, 2001). Practicing clinicians also require information that has been critically analyzed, typically combining the results of a number of studies and presented in clinically relevant form (Smith, 1996; Grandage et al., 2002). The past two decades have seen a shift from teaching individual clinicians how to evaluate the medical literature (Oxman et al., 1993) to

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

answering clinical questions through larger, organized approaches, best exemplified by the Cochrane Collaboration (The Cochrane Library, 2004), national task forces on prevention (CTFPHC, 2005; DHHS, 2005), and the Family Physicians Inquiries Network (FPIN, 2005), as well as numerous commercial endeavors. Most of these approaches are focused on interpretation and analysis of the medical literature; far fewer focus as well on the ability to search for and deliver the knowledge in a rapid and reproducible fashion. Yet both of these aspects of the process are critical if improved care and safety are to be realized.

There are two methods of delivering information to practicing clinicians—the passive lookup of information and the proactive interactive search for information. The Cochrane Collaborative is an example of a passive lookup information source. The collaborative has established a quality standard for creating critically reviewed clinical answers. The reviews are available through several channels, including the Internet, local intranets, and programs available on handheld devices (CC, 2005). A number of organizations are now designing ways to produce answers for busy clinicians (Epocrates, 2005; FPIN, 2005; JFP, 2005), including databases with tags for rapid searches and multiple delivery methods. Applications of this type are typically available in both web versions and versions that can be run on personal digital assistants (PDAs) (Ebell et al., 2002; Beattie, 2003; Lu et al., 2003; Barrett et al., 2004; Taylor, 2005). The current lack of Internet access from the bedside or examination room of most care locations in the United States has helped fuel PDA-based approaches to clinical information management (Rothschild et al., 2002). The rapid growth of PDA computing capabilities has spurred major advances in health information programs (Galt et al., 2005). The ability to update information daily, offer robust search capabilities, and imbed clinical algorithms in these programs enhances their utility for clinicians who are facile and regular users. Nonetheless, the stand-alone nature of these systems renders them but an intermediate step in the quest for robust knowledge management systems for health care providers.

Even with the enhanced compilation of clinical information and the improved databases and search engines of current knowledge management systems, applications that require the active engagement of a clinician will not be used as often as they should be. Full clinical decision support requires systems that support hyperlinks from data within an electronic health record (EHR) to information repositories (Kamel Boulos et al., 2002; Maviglia et al., 2005). Existing systems provide primarily links to static data, such as greater information on a laboratory test or drug monograph information. With improved capabilities for structured data capture, EHRs could facilitate the review of diagnostic features and testing, as well as choices among therapeutic options during patient care, through embedded

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

hyperlinks and queries based on real-time data (Kamel Boulos et al., 2002). The basic approach to data collection inherent in most EHRs in use today may need to be reconsidered if the power of such systems is to be fully realized. The power of appropriate structured clinical data linked to data repositories is illustrated by the Transhis project (Hofmans-Okkes and Lamberts, 1996; Okkes et al., 2001).

Pharmacotherapeutic Decision Support

As the complexity of medical care and medical treatments increases, appropriate and safe care requires that just-in-time information be routinely available to guide diagnostic, treatment, and monitoring activities. Linking of structured data in EHRs to clinical information repositories, together with continuous monitoring of decisions associated with selected activities, such as diagnosis, testing, and treatment, offers the best opportunity for rapidly improving the safety of care. Current working examples of this model are primarily in the pharmacotherapeutic arena, where monitoring of drug–allergy, drug–drug, and drug–disease interactions is common with computerized physician order entry (CPOE) packages. Unfortunately, the benefits of active alert systems have been offset in many cases by the high volume of clinically irrelevant messages, leading to frustration and alert fatigue among clinicians (Payne et al., 2002; Weingart et al., 2003), though this does not need to be the case (Shah et al., 2005). The poor concordance of the output of decision-support tools has also been noted (Abarca et al., 2004; Fernando et al., 2004). Indeed, low user acceptance of current active clinical decision-support systems may hinder the acceptance of EHRs overall, although reminder systems, typically based on patient gender and age (for prevention and screening activities) or diagnosis (for chronic disease care) are beginning to demonstrate the ability to improve care and gain user acceptability (McDonald et al., 1984; Shea et al., 1996; Burack and Gimotty, 1997; Hayes et al., 1999). Medication monitoring systems with carefully defined metrics (such as depression scales or bipolar screens) may become increasingly important as black box warnings become more common (Personal communication, Wilson Pace, February 8, 2006).

COMMUNICATION OF MEDICATION-RELATED INFORMATION

Providers should communicate patient-specific medication-related information in an interoperable format.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Lessons Learned from Hurricane Katrina: The Importance of Interoperable Medication Data

In 2005, after the devastation of Hurricane Katrina, the country witnessed some of the consequences of the failure to have health care data in an interoperable format. Until this time, although some experts and high-level administrators had some appreciation of the potential role of a national infrastructure for health care information, other key stakeholders, such as payers, did not fully recognize that potential (Sung et al., 2003). After Katrina left hundreds of thousands homeless and forced them to relocate, the health care system was left scrambling to supply these people with lost medications and medical equipment (GAO, 2005). Fortunately, companies such as Walgreens were able to retrieve patients’ medication lists, enabling providers to serve these individuals. States with immunization registries were able to retrieve these data so that children could enroll in new schools. Health care systems such as the Department of Veterans Affairs (VA) demonstrated the potential of national EHRs by having available all the information needed to piece together the pharmaceutical and other needs of their patients. Jonathan Perlin, undersecretary for health at the VA, perhaps stated the issue best when he said that after seeing how technology facilitated ongoing health care for Katrina victims, “you wonder why people use horse and buggy tools in the information age” (Bower, 2005).

The most significant event in terms of electronic access to Katrina victims’ medical information was the creation of Katrinahealth.org, an electronic medical record accessible to authorized doctors or pharmacists managing Katrina evacuees. The information on the site was compiled and made accessible within 4 weeks of the disaster by a broad group of private companies, public agencies, and national organizations, including medical software companies; pharmacy benefit managers; chain pharmacies; local, state, and federal agencies; and a national foundation. Katrinahealth.org is now a utility that can be used in any disaster.

Katrinahealth.org was formed from data that were in a format that supported their sharing and reuse. Three lessons were reinforced by this effort. First, it is vital that a medication list be accurate and complete. Pharmaceuticals, durable medical equipment (such as eyeglass prescriptions and settings for sleep apnea assistance devices), and important patient data (including medical conditions) are all potential or standard components of such a list. In addition, for these data to be maximally useful, they must be in a structured format including such components as the medication name, dose, route, frequency, duration, and start date. The messaging standard National Council for Prescription Drug Programs script (NCPDP, 2005), which is supported under the Medicare Modernization Act, already specifies this level of detail in its medication segment. Finally, these data must be

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

formatted in a way that unambiguously allows systems from different manufacturers to understand both their structure and content, so that, for example, all versions of a generic medication are identifiable by all systems required to review them. These last two principles are the essential characteristics of interoperability (James, 2005; Wallace, 2005).

Interoperability allows data to be easily aggregated, stored, retrieved into a single view, and shared. As emphasized in a recent report of the Commission for Systemic Interoperability (CoSI, 2005), interoperability allows national-level aggregation of data, making it possible to assess trends in emerging diseases or to recognize patterns of symptoms in cases of bioterrorism. Interoperability also has the potential to allow data access to be governed by a single set of rules, thereby providing patients with greater security and confidentiality.

Missing information is the rule rather than the exception in medicine (Smith et al., 2005). In a recent study of medical errors by Woolf and colleagues (2004), 80 percent of the errors were initiated by miscommunication, including a lack of communication between physicians, misinformation in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems.

Almost all health care situations can benefit from interoperable medication lists. Emergency department clinicians typically see patients without prior knowledge of their medications, problems, or allergies (Benson and Westphal, 2005; Kobusingye et al., 2005; Lappa, 2005). Primary care providers often do not know which medications have been prescribed by other providers or are actually being taken by the patient. In most health care settings, the lack of an accurate list of medications, problems, and allergies places patients at risk for ADEs due to drug–drug interactions or allergies (Benson et al., 1988; Carpenter and Gorman, 2002; Weingart et al., 2004). Although pharmacy chains may have a reasonably accurate list of medications, they rarely have accurate information about risk factors for potential ADEs, and they have no information about alternative and complementary medications, food supplements, or dietary habits that may affect drug metabolism and drug interactions (Isetts et al., 2003). This lack of information provided to pharmacists is especially concerning given their established role as a safety net in detecting potential errors (Kuyper, 1993).

Those with the greatest stake in detecting potential errors are patients and their families. Having an understandable list of medications, problems, and allergies can give patients and their surrogates the information they need to scrutinize their medications (Sutcliffe et al., 2004; Porter et al., 2005).

Sharing of medication data offers the potential to mitigate overprescribing and underprescribing (Waldron, 1977; Tafreshi et al., 1999); im-

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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prove the follow-up of patients taking medications, such as antidepressants (Simon et al., 2004, 2005); and address the rising problem of prescription drug abuse (Brushwood, 2003). In some cases, interoperable data on patient medications, problems, and allergies is already shared among pharmacy systems, but these data are accessible to few patients in their homes, physicians in the ambulatory setting, or emergency departments (Peth, 2003; Kaboli et al., 2004). These data could also provide important information for school nurses and chronic care facilities (Stupalski and Russell, 1999; Farris et al., 2003). The public health sector could benefit from such information as well. After Hurricane Katrina, for example, the Centers for Disease Control and Prevention was limited in its ability to conduct surveillance for illness and injury by such factors as misclassification of illnesses or injuries on the standardized form by participating facilities and the lack of aggregate baseline data, both of which would be improved by interoperability (CDC, 2005).

Role of Interoperability in the Transfer of Patients Between Sites of Care

The process of transferring patients and their information from one provider or site to another, also called “handoff,” is fraught with errors due to poor communication (IOM, 2000; Volpp and Grande, 2003; Solet et al., 2005). Many of these errors could be mitigated by the provision of an accurate history of medications, problems, and allergies. For example, hospitals do not routinely seek a medication record from a patient’s primary pharmacy. As a result, the admissions medication record is anecdotal and often omits or misrepresents medications that are being taken. Similarly, on discharge there is no communication back to the primary pharmacist of medication changes that have been ordered while the patient is in the hospital. Work conducted in the emergency departments of Indianapolis demonstrates the improvements that are possible when handoffs are supported by interoperable information systems (Overhage et al., 1995; McDonald et al., 2005). The improved safety associated with the provision of patient-specific medication information has been demonstrated for both emergency departments (Anglemyer et al., 2004; Croskerry et al., 2004) and the inpatient setting (Petersen et al., 1998). Indeed, interoperable medication data can improve the safety of care generally and of medication use in particular in handoffs involving all care settings.

Both paper and electronic formats can be used to improve patient care and patient safety (Tufo et al., 1977; Weed, 2004). However, electronic tools for data capture (order entry) and retrieval offer automated consolidation of data from multiple sources (Overhage et al., 1995; Finnell et al., 2003), remote access as needed (Torre, 2004), and automated decision support (Bates et al., 1995b, 1999, 2001; Abookire et al., 2000; Grasso et

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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al., 2003; Kaushal et al., 2003; Field et al., 2004). CPOE systems for both ambulatory and inpatient care support faxing, messaging, and bidirectional communication of prescription information (eHI, 2004). Each of these tools improves access to original data and provides these data in a format that is legible and potentially interoperable.

In sum, the availability of interoperable data is a lynchpin of a safer health care system, as noted by the Institute of Medicine (IOM) in its report on patient safety (IOM, 2004). Systems provided with these data are uniquely able to provide health care providers with feedback on aspects of their medication prescribing practices about which they might otherwise be unaware (Meyer, 2000; Galloway et al., 2002). This information can also be used for continuing medical education (CME) and evaluation as a part of maintenance of certification, helping providers remain current with the best practices for safe health care delivery. Research suggests that when provided with information on how their behavior can be improved in a timely fashion, health care providers will make these changes (Neilson et al., 2004). Finally, it must be emphasized that as noted by the Commission for Systemic Interoperability, “Having an electronic medication record for every American is a critical step toward achieving true interoperability in healthcare, giving treating physicians the information they need when they need it, allowing more effective care for their patients. It will bring all the medications an individual is currently taking to the doctor’s attention at the time important decisions about new prescriptions are being made” (CoSI, 2005).

In effect, interoperable medication data can facilitate more efficient medication reconciliation,2 particularly at admission and discharge, when discrepancies are an important problem and a frequent cause of ADEs (Forster et al., 2005). Providing such data electronically is even more important now that JCAHO has established that by 2006, hospital organizations must institute a process for comprehensive medication reconciliation at admission, at transitions to and from internal patient care units, and at discharge with the “next provider of service.” Interoperable medication data will be the most feasible approach to accomplishing this goal.

MONITORING AND SAFETY IMPROVEMENT

Providers should assess the safety of medication use through active monitoring and use these monitoring data to inform the implementation of prevention strategies.

2

Reconciliation involves comparing what a person is taking in one setting with what is being provided in another setting to avoid errors of transcription, omission, duplication of therapy, and drug–drug and drug–disease interactions.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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BOX 5-6

Detection Methods for Medication Errors and ADEs

  • Attendance at medical rounds or review of nurse change-of-shift reports to look for clues that an error has occurred (Andrews et al., 1997; Baker, 1997)

  • Chart review (Bates et al., 1995a,b)

  • Comparison of drugs removed from an automated drug dispensing device with physician orders (Shuttleworth and Ruelle, 1996)

  • Computerized analysis to identify patients receiving target drugs that may be used to treat a medication error or a search for serum drug concentration orders that may indicate an overdose (Bates et al., 1995b)

  • Direct observation for detecting medication administration errors (Allan and Barker, 1990; Barker et al., 2002)

  • Monitoring of doses returned to the pharmacy (indicating possible dose omissions) (Gift et al., 1996)

  • Examination of death certificates (Phillips et al., 1998)

  • Comparison of medication administration records with physician orders (Cunningham et al., 1996)

  • Voluntary reports of medication errors (Phillips, 2002)

  • Stimulated self-reports using interviews (Bates et al., 1995a,b)

  • Urine testing as evidence of omitted drugs and unauthorized drug administration (Ballinger et al., 1974)

Accurate counting of medication errors and ADEs using appropriate detection methods is now possible and is critical for establishing the scope of the error problem. Accurate counts also enable providers to assess the impact of error prevention efforts. The discussion in this section focuses on what health care providers can do to improve medication safety through the use of error detection and monitoring techniques; the use of external reporting programs for safety improvement, introduced in Chapter 2, is discussed in Chapter 8.

Many health care systems monitor medication errors by tracking self-reported errors. Experts generally acknowledge that such reports detect a small percentage of the true number of errors and ADEs, but they believe this approach is the only feasible option. There are, however, better methods for counting errors. The goal of the committee’s recommendation in this area is to assist health care providers in selecting improved methods for monitoring of medication errors and ADEs while maintaining the recognized benefits of current reporting mechanisms.

Numerous detection methods for medication errors and ADEs have been employed (see Box 5-6). The selection of a method for inpatient settings can be facilitated by answers to the following questions:

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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  • Are we most interested in focusing on medication errors for inpatient settings that lead to patient injury (ADEs)? If yes, review the methods described in Table 5-1.

  • Are we interested in detecting as many errors as possible for inpatient settings so that real system problems can be identified more quickly and prevention efforts prioritized? If yes, review the methods described in Table 5-2.

  • ADE and error detection methods for outpatient settings are summarized in Table 5-3.

Some of the methods available for detecting errors and ADEs are described in greater detail below. These include reporting, chart review, computerized detection of ADEs (Classen et al., 1991; Evans et al., 1991; Bates et al., 2003), observation of medication administration (Barker et al., 2002),

TABLE 5-1 ADE Detection Methods: Inpatient Setting

Detection Method

Description

Source of Data

Chart review (see Morimoto et al., 2004)

Data sources are screened for evidence that an ADE occurred

Medical record (including electronic notes), orders

Computer-generated signals

Computer screens orders, laboratory values, and other data for indicators that an ADE may have occurred; reviewer follows up on results

Triggers from computerized data (e.g., laboratory results, order for antidote)

Electronic notes

Software screens chart for evidence of an ADE; reviewer follows up on results

Electronic health record, discharge summaries (Murff et al., 2003)

Self-report, voluntary

Providers submit data about events

Patients, medical record

Self-report, prompted

Providers are interviewed to see whether any incidents have occurred

Providers

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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and audits of prescriptions filled in community pharmacies to monitor dispensing errors (Flynn et al., 2003).

Resources

Advantages

Disadvantages

Trained reviewers (nurses, pharmacists)

Most likely to identify events resulting in patient harm; detects more events than self-reports (Jha et al., 1998)

More time-consuming if computer-generated signals are unavailable

Software, trained reviewers

Helps focus reviewer time by using triggers; has the highest positive predictive value for ADEs (see Field et al., 2004); identifies more events than self-reports (Jha et al., 1998)

Best at finding events associated with numbers (Gandhi et al., 2000); availability of electronic data required

Software, trained reviewers

Detects high percentage of ADEs in an efficient manner (see Field et al., 2004)

Electronic record or discharge summaries needed

Providers, report monitoring system and staff

With sufficient data, can identify error and ADE trends; description of event can help trained staff find cause

Detects very small percentage of events

Trained staff to conduct interviews

In addition to advantages of voluntary self-reports, can be performed by attending rounds and nurse shift changes

Detects small percentage of events

Reporting of Medication Errors and ADEs

Voluntary reports, while not appropriate for measuring the actual frequency of errors, are useful as a basis for root-cause analysis and for identification of error trends involving certain medications, doses, forms, and routes. Trend analyses and data mining benefit from having very large databases—hence the efforts being made to increase error reporting and to combine databases (see Chapter 8).

Health care providers can take a number of actions to promote successful medication error reporting in their respective settings. First, they

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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TABLE 5-2 Medication Error Detection Methods: Inpatient Setting

Detection Method

Description

Source of Data

Chart review

Data sources are screened for evidence that an error occurred

Medical record

Observation

Observer records medications administered and compares with orders, or observer shadows physician (Rothschild et al., 2005)

Personnel actions

Self-report, voluntary

Providers submit data about events

Patients, medical record

Self-report, prompted

Providers are interviewed to see whether any incidents have occurred

Providers

can create a learning system whereby errors and recommended preventive measures are reported and used as a tool for learning. Second, they can make a commitment to learning about error problems, monitoring national trends and reports, and implementing plans designed to prevent similar errors from occurring at their site. When errors and ADEs are identified, reporting should be encouraged. For example, the Institute for Safe Medication Practices’ (ISMP) Medication Safety Alert newsletter, United States Pharmacopeia (USP) MedMARx reports, and case studies from AHRQ’s Web M&M (http://www.webmm.ahrq.gov) should be required reading for health care practitioners, including community pharmacists, who can learn about errors that have occurred and take action to avoid them. Recommended preventive actions, based on expert review, are included in the ISMP newsletter.

As noted, voluntary reporting is valuable for identifying large problems and providing a stimulus for change, but has recognized limitations for evaluating the true frequency of medication errors and ADEs. In a comparison of voluntary reports against observation in 36 health care facilities, observation detected 456 times more errors (Flynn et al., 2002).

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Resources

Advantages

Disadvantages

Trained reviewers

Detects more events than self-reports (Flynn et al., 2002)

More time-consuming if computer-generated signals are unavailable

Trained observers (nurses, pharmacists)

Detects greatest number of medication administration errors (Flynn et al., 2002); identifies clues to causes of errors that may not be found with other methods

Focuses on administration errors

All providers, report monitoring system and staff

With sufficient data, can identify error and ADE trends; description of event can help trained staff find cause

Detects small percentage of events

Trained staff to conduct interviews

In addition to advantages of voluntary self-report, they can be performed during attending rounds and nurse shift changes

Detects small percentage of events

To increase the strength of the evidence that errors truly are being reduced (or are increasing), additional, more robust error detection methods are needed.

Chart Review

Chart review to identify medication errors involves looking for events in patient documentation that indicate a medication error may have occurred, for example, a change in mental status, a new rash or diarrhea, or orders for antidotes. Chart review is an effective way of finding medication errors and ADEs, but is costly to perform and requires special training for the chart reviewers. Recently, chart review has begun to make use of an ADE trigger tool designed by the Institute for Healthcare Improvement (Rozich et al., 2003), which is based on the automated surveillance methodology created at LDS Hospital, Salt Lake City (Classen et al., 1991). Such ADE trigger tools do not require computerized technology and have been used successfully to demonstrate the benefits of low-cost error prevention

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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TABLE 5-3 ADE and Medication Error Detection Methods: Outpatient Setting

Detection Method

Description

Source of Data

Chart review (Gandhi et al., 2003; Morimoto et al., 2004)

Review of patient’s clinic medical record for evidence of an ADE

Medical record

Computer-generated signals (Field et al., 2004)

Computer screens orders, laboratory values, and other data for indicators that an ADE may have occurred; reviewer follows up on results

Triggers from computerized laboratory data

Evaluation of prescriptions (Flynn et al., 2003)

Contents and labels of filled prescriptions are compared against the original order for discrepancies (detects dispensing errors)

Filled prescriptions

Reports, voluntary

Patients or providers may identify an error and report it to the provider or other organization

Patients (symptoms or filled prescriptions)

Survey of patients (Wertheimer, 1973; Forster et al., 2003; Morimoto, 2004)

Patients are interviewed after care or receipt of a prescription to find evidence of ADEs or dispensing errors

Patients

strategies focused on high-risk medications in community hospitals (Cohen et al., 2005).

Computerized Detection Methods

Electronic detection of ADEs should be included in clinical software programs in all areas of health care by 2010. This capability can support early detection of patient harm, with subsequent intervention to correct the problem and treat the patient. Incorporation of this critical feature is important today, at a time when CPOE and EHRs are being developed and implemented. The IOM’s Patient Safety report describes the functional requirements for electronic ADE detection systems, including rules for detecting possible ADEs using automated surveillance (Evans et al., 1991; Classen et al., 1991; Bates et al., 2001; IOM, 2004).

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Resources

Advantages

Disadvantages

Trained reviewer

Most likely to identify events resulting in patient harm

Fewer ADEs detected compared with patient surveys

Software; trained reviewers

Most likely to identify events resulting in patient harm

Limited availability of software in this setting in the short term

Pharmacist

Good measure of dispensing errors; provides clues to causes of errors

Dependent on availability of staff and time

Health care provider

Can provide clues to the causes of errors

Small numbers involved; should not be used for rate calculations

Health care provider

Can be used to follow up on symptoms, obtain additional information

May be time-consuming if no electronic screening is available

Computerized detection of ADEs is based on the use of screening criteria for triggering events. Techniques used by such systems include examining medication orders for antidotes (indicating a wrong dose or wrong drug) and screening clinical laboratory data for results that exceed critical values. These techniques may be employed at various levels of sophistication (Bates et al., 2003). Once a potential ADE has been identified, clinical review is necessary to confirm whether it was in fact such an event.

Observation of Medication Administration

Since 1960, studies have used nurses to observe medication administration in hospitals because the results provide an accurate measure of how often medication administration errors actually occur (Flynn et al., 2002). Observation involves a trained nurse or other health care profes-

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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sional shadowing the nurse who administers medications, recording the medications prepared and administered, and comparing this information with what the prescriber ordered. Any discrepancy between what the patient received and what the prescriber ordered is an administration error. These data have been used to evaluate the accuracy of the output of the entire medication distribution system—whether the patient received the right drug, dose, form, and route—from the patient’s point of view (Barker et al., 2002). An important advantage of observation over voluntary reporting is that it does not rely on the heath care provider’s being aware of the error (providers typically do not realize they have made an error, and if they do, they may be reluctant to report it). Observation is best performed by nurses or pharmacists, although less costly resources, such as pharmacy residents, pharmacy or nursing students, or experienced pharmacy technicians, can also be used. The average cost of observation per dose was measured in one study as $6.65 when performed by a registered nurse and $4.56 by a licensed practical nurse (Flynn et al., 2002). Observation has been recommended for studying ADEs as well (Rothschild et al., 2005).

To derive the benefits of the lessons that can be learned from observation while keeping the process affordable, observation is best conducted for limited or periodic studies of settings of interest. The number of observations depends on the goal of the study, ranging from 100 per nursing unit over a day or two to see whether there is an error problem to over 1,000 for evaluations of technology effects. A hospital might conduct an observation on several nursing units selected as “typical” every few months to learn from the errors detected and determine whether there is a serious error problem. This process would be part of the hospitals routine quality monitoring program.

Audits of Prescriptions Filled in Community Pharmacies

Detection of medication errors and ADEs in ambulatory care settings is a fairly recent development. For example, incident reports and review of patient records have been used to study ADEs among elderly ambulatory patients (Gurwitz et al., 2003). Medication dispensing errors on prescriptions filled in community pharmacies have been studied using a double-check by an independent observer pharmacist (Flynn et al., 2003); however, the standard in pharmacies is to rely on self-reports of errors detected by patients who notify the pharmacist. National databases of voluntary reports contain few error reports from the ambulatory setting, in part because of unawareness of such errors and in part because pharmacies do not want this information reported to external organizations. With the enactment of

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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the Patient Safety and Quality Improvement Act of 2005 (P.L. 109-41), protecting such data reported to patient safety organizations, community pharmacies should start sharing this information.

Audits in community pharmacies involve random inspections of prescriptions waiting to be picked up. A double-check of the contents of the prescription vial compared with the drug and strength listed on the label can help detect wrong-drug and wrong-strength errors that may have avoided detection during the normal processes. The patient name on the vial can be compared with the identifying information on the bag to help detect wrong-patient errors. An additional audit technique is to review information entered into the computer for new prescriptions for accuracy. Use of such a quality improvement process at a VA outpatient pharmacy resulted in a decrease in serious errors (ones that could have led to patient harm) from 0.6 percent to 0.1 percent of prescriptions over a 1-year period (Boneberg et al., 1991).

Analysis of Safety Data

Time spent detecting, reporting, and analyzing medication errors and ADEs is wasted if the resulting information is not used to prevent future errors and injuries. USP publishes focused analyses based on voluntary reports made to the MedMARx database, which are helpful in identifying problem areas and can serve as one model for how to use this type of data (Young, 2002; Hicks et al., 2004; Santell et al., 2004). As noted earlier, the ISMP newsletter contains not only descriptions of problems reported, but also suggestions for preventing future errors (ISMP, 2005a). And AHRQ’s Web M&M site also provides clinically useful analyses of medication errors. Medication error databases at all levels should have a greater ability to track effective methods for preventing the errors described, with a requirement to report on follow-up actions taken and their effectiveness.

An important benefit of using the techniques of computerized detection and observation described above is that they can be used to evaluate interventions (Evans et al., 1994a, 1998). Observation, for example, enables valid measurement of the effects of error prevention efforts on medication administration errors. Studies that use voluntary reports to assess interventions cannot determine whether an intervention led to a decrease in errors or whether staff were unaware of errors that occurred.

The knowledge base on effective error prevention techniques should be advanced at all levels (local, state, and national). The ultimate goal is to have in place a system that facilitates the identification of best practices for preventing errors and dissemination of this information to providers across settings of care.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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ELECTRONIC PRESCRIBING

By 2010, all prescribers should write and all pharmacies should be able to receive prescriptions electronically. By 2008, all prescribers should have plans in place to implement electronic prescribing. Providers should subject prescriptions to evidence-based, current clinical decision support.

Increasing evidence demonstrates that paper-based prescribing is associated with high error rates (Bates et al., 1995a; Kaushal et al., 2003) and that electronic prescribing is safer (Bates et al., 1998). Electronic prescribing has a number of advantages (Bates et al., 1999; Teich et al., 2005): it eliminates handwriting, helps ensure that the key fields (for example, drug name, dose, route, and frequency) contain meaningful data, and makes it possible to suggest a default dose. More important, however, computerized prescribing enables a range of clinical decision support (Teich et al., 2005), including checks for allergies, drug–drug interactions, overly high doses, clinical conditions, drug–laboratory issues, and pregnancy-related issues, as well as suggestions about dose given the patient’s level of renal function and age.

While all decision-support checks contribute to an effective medication-use system, results of recent studies suggest that dose adjustment may be especially important. It is clear that 10-fold dosage calculation errors in particular are a major clinical issue, especially in pediatrics (Rowe et al., 1998). One inpatient study found that suggesting a dose appropriate for a patient’s level of renal function substantially improved the likelihood that the patient would receive the appropriate dose of medication (Chertow et al., 2001); another demonstrated that alerts decreased the likelihood that patients would receive too high a dose of medication given their level of renal function (Galanter et al., 2005). Another study (Peterson et al., 2005) demonstrated that suggesting an appropriate starting dose of medication for geriatric inpatients improved the likelihood that the recommended daily dose would be prescribed, reduced the likelihood of 10-fold overdose, and was associated with a lower rate of falling.

It is not easy to implement decision supports, however, and problems can arise with all of them. For example, many issues remain to be addressed with regard to allergy checking, although some best practices have been suggested (Hsieh et al., 2004). Drug–drug interactions are especially complex since so many have been identified, but the number that are clinically important is more modest (Hansten et al., 2001; Peterson and Bates, 2001; Glintborg et al., 2005). Fewer data are available regarding the frequency of problems in such areas as diagnoses contraindicating drugs, generic checks for overly high doses, and drug–laboratory decision support.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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It is also essential that any decision support be practical. Overalerting is a frequent and important problem (Teich et al., 2005), especially for drug– drug interactions. To avoid this problem, it would be helpful if decision support rules were available in a publicly available location. AHRQ should consider approaches for developing a database to which organizations could contribute decision-support rules, expressed in a standard format, that could then be accessed by interested parties. This database would require periodic external vetting to ensure that it included only appropriate rules and to update the decision-support knowledge base. The need for such quality checks is illustrated by ISMP’s recent audit of pharmacy decision support, which found a very high rate of deficiencies and no improvement over a 6-year period (ISMP, 2005b).

An important adjunct to electronic prescribing is that all pharmacies should be able to receive prescriptions in coded form—a much lower-risk method than current paper or oral approaches (Bates, 2001), which are error-prone and require transcription and verification. A commonly used approach in the outpatient setting, for example, is to call prescriptions in to the pharmacy. These prescriptions are frequently left on voice mail. This approach, while efficient in some respects, has several limitations: there is no possibility of readback; if there is a problem, the pharmacist must contact the prescriber later; and the prescription cannot be checked at the time it is delivered to the pharmacy. Similarly, in the reverse direction, most communication by the pharmacist to the prescriber’s office must be left on voice mail, and sometimes the prescriber’s staff do not respond appropriately to queries requiring a clinical response. At the same time, a number of issues must be addressed for electronic transmission of prescriptions to be practical. Many of these issues are regulatory. For example, a number of states have laws that preclude the practice, particularly for narcotics, although there is no evidence that handwritten prescriptions are safer. In other situations, pharmacies can decide whether they will accept electronic transmission, a situation that creates substantial problems for providers attempting to implement safer prescribing practices.

It is also important to recognize that any technology can induce new errors as well as prevent them, and that computerization of prescribing thus does not represent a panacea (Koppel et al., 2005). When any intervention is introduced, it must be monitored, problems it creates must be identified, and appropriate changes must be made in the application and underlying databases to eliminate these problems. Typically, insufficient resources and energy are dedicated to this process, yet results of human factors research clearly demonstrate that it is more efficacious than training staff to work around difficulties (Gosbee, 2004).

Finally, to achieve the desired safety benefits, electronic prescribing must include basic clinical decision support (Bates et al., 1999; Gandhi et

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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al., 2005), which in turn requires a defined set of clinical data—the patient’s age, gender, allergies, other medications, problems, and selected laboratory results. Thus to achieve major safety benefits, electronic prescribing should be linked with electronic health records. It should be carried out using a device such as a desktop, laptop, or tablet computer. To date, it has been impossible to deliver adequate clinical decision support on palm-top platforms, primarily because of the infeasibility of incorporating sufficient clinical information in these devices in a timely fashion, the shortage of space on palm-top screens, lack of interoperability, and issues related to transmission speed. The tablet PC provides more screen space than the palm-top device at the cost of some portability.

MULTIDISCIPLINARY TEAMS

Providers should have the appropriate competencies for each step of the medication-use process.

The use of multidisciplinary teams to care for patients receiving complex medication regimens offers the potential to improve substantially the quality of drug therapy and reduce the occurrence of medication errors and ADEs (Leape et al., 1999). Such teams may include nurses, clinical pharmacists, and other health professionals, complementing and extending the efforts of the physician. In most instances, it is useful to enlist the patient and family members as part of the overall team. In certain instances, having specific individuals on the team can be beneficial. For example, having a pharmacist conduct rounds with the team has been found to reduce ADE rates in the intensive care unit setting (Leape et al., 1999). While it probably does not make sense to have pharmacists present during rounds with all teams because of the cost of their services, their input on teams providing care that involves high medication use (for example, chemotherapy units) is likely to provide important benefit.

Multidisciplinary approaches have been employed to optimize pharmacotherapeutic management of patients across a variety of clinical settings, from the intensive care unit to the ambulatory setting. These approaches have often focused on specific medical conditions, such as diabetes mellitus and congestive heart failure (Rich et al., 1995; Whellan et al., 2005), or specific drug therapies, such as anticoagulant therapy.

Cohesive health care teams possess five key characteristics (Grumbach and Bodenheimer, 2004):

  • Clear goals with measurable outcomes

  • Clinical (e.g., for prescription refills) and administrative (e.g., for making patient appointments) systems

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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  • Division of labor—identifying which people on the team perform which tasks

  • Training for the functions each team member routinely performs

  • Effective communication (e.g., minute-to-minute communication through brief verbal interactions among team members)

How these characteristics play out in the care of patients on drug therapy can be illustrated by the example of anticoagulation therapy with warfarin. Such therapy is risky, for example, because of the possibility of bleeding due to drug interactions and suboptimal dosing. Specialized anticoagulation clinics employ a team approach to optimize the treatment (Ansell et al., 1997). Such an approach can help achieve improvements in anticoagulation control (Samsa et al., 2000) and reductions in bleeding and thromboembolic event rates (Chiquette et al., 1998; Hamby et al., 2000). One measurable outcome for patients on warfarin therapy is whether the level of anticoagulation has been maintained within the target therapeutic range at least 80 percent of the time, so as to reduce the risk of bleeding and provide optimal therapeutic benefit. Accordingly, key features of effective warfarin therapy teams are as follows:

  • A clinical system with a set of procedures for informing patients of laboratory results and of any needed changes in the warfarin dose.

  • An administrative system with procedures for scheduling the next laboratory test and notifying the nurse and scheduler when a patient does not present for the test.

  • Adequate training of each team member in the specific functions each must perform. For example, the nurse or pharmacist managing the care of patients on warfarin must be trained in the use of protocols and computer programs for dosing and monitoring of the therapy, as well as in surveillance for important drug interactions.

  • Communication structures for promptly conveying information to the physician when there is a need for decisions regarding response to a warfarin-related bleeding event or complex dosing and monitoring decisions not encompassed by the usual protocols.

It is important to note that despite the potential benefits of multidisciplinary approaches and their increasing use in the care of patients with a variety of medical conditions, such approaches have not always proven to be more effective than conventional care (Matchar et al., 2002; Strom and Hennessy, 2002). Furthermore, multidisciplinary teams are used most commonly in care for a single medical condition or management of a single type of therapy. Care provided by several different multidisciplinary teams may not be the optimum way to care for patients with multiple chronic medical

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

conditions. Indeed, such a fragmented approach could place patients at increased risk for medication errors, similar to the risk that results from having multiple different health care providers each independently prescribing medications in their own discipline. An example of an alternative is the Program of All-Inclusive Care for the Elderly (PACE), which has shown great promise for providing comprehensive care for the very frail elderly using a multidisciplinary approach (Bodenheimer, 1999).

The committee believes that a team approach to medication use is essential. Different providers will be involved at each step of the process. But all providers who are prescribing, whether a physician, nurse practitioner, or physician’s assistant, or administering, whether a registered nurse or licensed practical nurse, need to have the appropriate competencies, which should be determined by their professional organizations and the care organization for which they work.

EFFECTIVE USE OF WELL-DESIGNED TECHNOLOGIES

Providers should make effective use of well-designed technologies, which will vary by setting.

Judicious use of technology will be important in improving medication safety (Bates and Gawande, 2003). While the evidence supporting this statement is strongest for the inpatient setting (AHRQ, 2005), the use of technology will undoubtedly result in major improvements in all settings, although the specific technologies and relative benefits will likely differ by setting. Much remains to be learned in all settings. Moreover, as noted earlier, any technology can introduce errors as well as prevent them (Ash et al., 2004), and it is essential to monitor any new technology and make appropriate midcourse corrections. And even highly promising technologies may not yield the desired safety benefits if issues of safety culture and efficiency are not adequately addressed (Rothschild, 2004).

Inpatient Setting

In the inpatient setting, strong evidence demonstrates that CPOE reduces rates of serious medication errors in adults (Bates et al., 1998; AHRQ, 2005), although the impact on preventable ADEs is uncertain since a large randomized controlled trial has not been conducted. A key issue regarding CPOE is the depth and breadth of the decision support provided. Moroever, the main impact of CPOE is on ordering and transcription errors; the technique has relatively little impact on administration errors. For reducing the frequency of the latter errors, machine identification techniques such as

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

bar coding—especially when linked to an electronic medication administration record—hold substantial promise, although the evidence for their efficacy is less strong than is the case for CPOE (AHRQ, 2005). Bar coding will likely be especially important for medications taken orally, although it will probably also be important for intravenous medications. The latter are particularly risky because they are especially potent, have rapid action, and are given to critically ill patients, and because it is easy to give an intravenous dose that exceeds the norm by 10 (or more) times. Another technology that appears likely to have an impact on improving the safety of intravenous medications is “smart” pumps. These pumps can be programmed according to the medication being given, warn the nurse if the dose is too high, and record what happens if the dose is overridden. The first large trial of this technology demonstrated that it could be used to identify many instances in which doses were too high, but it did not reduce the rate of serious medication errors because nurses often ignored even important warnings (Rothschild, 2004).

Although dispensing appears to be relatively safe compared with other steps in the medication-use process, it, too, can be made safer by bar coding (Poon et al., 2005). The use of robots for filling prescriptions in pharmacies may also have the potential to improve dispensing (Bates, 2000). Automated dispensing devices on clinical units may improve safety as well, although the one study evaluating their impact failed to demonstrate any benefit (Barker, 1995; Barker et al., 1998).

Monitoring should also benefit from computerization in two ways. One is that the standard approach to identifying ADEs—spontaneous reporting on paper—should be replaced by on-line reporting, which has many advantages (Bates, 2002). Specifically, on-line reporting makes it possible to use branching logic; makes it easier to update the reporting scheme; and facilitates collection of the data in standard formats, which in turn facilitates analysis. Much more important, though, is implementation of computerized ADE monitoring (Classen et al., 1991) that uses signals to identify situations in which an ADE has occurred or is likely to occur. In many instances, it may be possible for someone—usually a pharmacist—to intervene either before the event occurs or before it becomes as severe as it might otherwise have been.

There have been a few studies of override problems related to technologies designed to reduce medication errors. As noted above, a smart pump can fail to reduce serious medication error rates because nurses ignore important warnings (Rothschild, 2004). At the prescribing stage, Hsieh and colleagues found that overrides of allergy warnings were common, and 1 in 20 of these overrides, while appearing to be clinically appropriate, resulted in an ADE (Hsieh et al., 2004). At the pharmacist order entry stage, Grisso

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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and colleagues (2004) found that 6.5 percent of overdose and underdose warnings for pediatric patients were inappropriate, and a daily review of pharmacist overrides is now performed to correct problems early in the process. At the medication administration stage, Oren and colleagues (2002) studied overrides of antimicrobial withdrawals from an automated dispensing machine and found that medication errors occurred in 21 percent of cases. Kester (2005) found that 12 percent of overrides were associated with variances from written orders, and 2 percent were related to medication errors or near misses. A unit-based pharmacist can help decrease medication errors resulting from overrides (Haas et al., 2004), and a well-implemented system should include education about the possible implications of overriding system warnings.

Ultimately, it will be important to implement all of the above technologies at the same time and link them electronically. Orders can then be transmitted electronically to the pharmacy, where they can be evaluated and filled. It should be possible to do this for many medications, with manual filling being checked using bar coding for a small minority of medications. The electronic medication record can then be populated. Nurse administration of medications taken orally can be checked through bar coding, while intravenous medications can be screened using smart pumps. All of these techniques should be able to communicate wirelessly. Many of these approaches, especially CPOE and automated dispensing in the pharmacy, will be easier to support in larger, rather than smaller, hospitals. With this combined approach, it might be possible to reduce the medication error rate in hospitals on the order of 100-fold.

Nursing Home Setting

In nursing homes, electronic prescribing will likely be important, although there are few data to date regarding its efficacy in this setting, and the key decision support required will likely differ somewhat from that in the inpatient setting (Gurwitz et al., 2005; Rochon et al., 2005). Therefore, CPOE is likely to yield substantial benefits, especially if it can be done remotely, enabling the physician to review the patient’s medication list and perform checks, such as those for drug–drug interactions, in real time (Rochon et al., 2005). This is a particular problem in nursing homes as many residents are taking multiple medications, and most physicians are not located at the site. Nonetheless, implementation of CPOE in this setting will be challenging since most nursing homes have very limited resources, and many have relationships with large numbers of physicians who spend relatively little time at each site.

Bar coding and computerized medication administration records can also be expected to have an impact in this setting. Barker and colleagues

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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(1982) demonstrated relatively high rates of medication administration errors in nursing homes and the potential of bar coding to decrease these rates, although controlled trials of this technology have not been conducted in this setting.

Outpatient Setting

In the outpatient setting, electronic prescribing will be important (Gandhi et al., 2003), although evidence to date for its effectiveness in this setting is limited, and electronic prescribing without associated decision support is unlikely to yield the potential safety benefits (Gandhi et al., 2005). Indeed, it may be more important to improve communication between patients and providers; the available evidence suggests that many ADEs might have been prevented or ameliorated had communication occurred earlier in the medication-use process (Gandhi et al., 2003). In this regard, personal health records that are linked to provider EHRs represent one attractive approach that deserves further evaluation (Katz et al., 2004). Other technologies, such as on-line communications, also warrant further investigation. In addition, automation may be useful in pharmacies to improve the likelihood that prescriptions will be filled accurately, and to free pharmacists to do more counseling with patients, which too often does not occur today.

Return on Investment

The adoption of CPOE with computerized decision support has been slow (Kaushal et al., 2005). High upfront capital costs and the difficulty of demonstrating the financial benefits have been major barriers to the adoption of CPOE. A recent study demonstrated that the investment in CPOE with decision support at the Brigham and Women’s Hospital, Boston, Massachusetts, has resulted in substantial operating budget savings (Kaushal et al., 2006). Over the period 1993–2002, the hospital invested $11.8 million to develop, implement, and operate a CPOE system and achieved net operating budget savings of $9.5 million. The majority of the savings were derived from a relatively small number of interventions. The annual savings generated in 2002 dollars were from renal dosing guidance ($2.24 million), ADE ($1.05 million), improved nursing time utilization ($0.96 million), and specific/expensive drug guidance ($0.88 million).

A key lesson from the implementation of CPOE with computerized decision support at Brigham and Women’s Hospital is that hospitals should focus initially on a small number of high-impact interventions (for example, renal dosing guidance, ADE prevention, and specific/expensive drug guidance). There are other high-impact interventions not implemented at Brig-

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

ham and Women’s Hospital, such as the antibiotic assistant implemented at LDS Hospital, Salt Lake City (Evans et al., 1994b). More research is needed to identify further high-impact interventions, particularly regarding the use of intravenous medications because of their high toxicity.

Another key lesson from the implementation of CPOE at Brigham and Women’s Hospital is that hospitals should pay careful attention to workflow design to save nursing and physician time. At Brigham and Women’s Hospital, the greatest efficiency was achieved through automation of the medication administration record. Other savings were derived from reduced rework of problematic orders to avoid medication errors or ADEs since the CPOE system was performing many of these checks at the time of order creation.

Further cost/benefit studies are urgently needed. The system implemented at Brigham and Women’s Hospital was developed in house, so studies of vendor-based systems are particularly desirable. Also needed are studies addressing care settings other than hospitals and a broader range of decision-support tools.

Implementation of Systems

The overall design and implementation of new technologies are fundamental to a successful outcome. Groups of researchers have documented implementation problems for electronic prescribing systems and unintended consequences arising from the implementation of such systems (Ash et al., 2004; Han et al., 2005; Berger and Kichak, 2004; Koppel et al., 2005; Fernando et al., 2004). Achieving the safety benefits of any technological intervention, but perhaps especially CPOE, requires that it be implemented well and routinely maintained. A number of best practices for implementing CPOE and the associated clinical decision support have been described:

  • There are many CPOE systems available, and careful analysis is needed to identify the best system to meet the needs of the clinical situation. Entry and retrieval of information is an aspect of CPOE that must be examined with particular care (Ash et al., 2004).

  • The success of the implementation of information systems in health care is determined by organizational factors (Aarts et al., 2004). Care delivery processes and the technologies to support these processes need to be designed in conjunction. A corollary is that significant effort must be devoted to staff training in the use of CPOE systems.

  • All electronic prescribing applications should be subjected to usability testing and evaluation with test scripts before implementation. Leapfrog is developing a tool for evaluating hospital CPOE systems with decision support (Kilbridge et al., 2006). Currently, EHRs are being certified by the

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Certification Commission on Health Information Technology, which will be certifying electronic prescribing applications if they are part of EHRs. It is also useful to pilot the CPOE in a limited setting prior to full implementation to identify and rectify any problems.

  • During the implementation period, it is best to include as many order sets as possible at the outset and to provide intensive support to all users so that any problems can be rapidly addressed.

  • After implementation, use of the CPOE system must undergo a continuous quality improvement process (Bates, 2005) with frequent evaluation to determine whether the system is functioning as intended, and new errors that are introduced must be tracked and addressed. The clinical processes involved are complex. Errors and problems will continue to occur. Sufficient resources must be available to analyze problems and implement process improvements. Several models of successful quality improvement in clinical units have been documented (IOM, 2004; Batalden et al., 2003; Pronovost et al., 2002). The above practices apply for any clinical decision support system as well.

Care Transitions

Data increasingly suggest that care transitions are associated with high levels of risk (Forster et al., 2003), especially for ADEs (Forster et al., 2005). Many of these ADEs are due in part to the changes in medication that are made at the time of admission or discharge. Thorough reconciliation of medications is crucial in these situations (Rozich et al., 2004), but difficult to achieve. Technology can assist in this process. In addition, outreach to patients who have recently been discharged will likely be necessary, and it appears likely that technology such as telemedicine and personal health records can be used to leverage this outreach.

Conclusions

In the future, it is inevitable that technologies will serve as increasingly important tools for improving medication safety in all settings, though the specific technologies involved will differ by setting. For inpatients, the core challenge appears to be accurately delivering the appropriate and intended medications. Outside the hospital, improving the safety and efficacy of prescribing is essential, together with improving monitoring and communication. In all settings, safety culture is pivotal, and there are many things that individual providers can do to that end, though achieving high levels of safety will demand that providers have tools appropriate for their setting. These tools must be implemented well, and all carry the potential for unintended consequences.

Suggested Citation:"5 Action Agenda for Health Care Organizations ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

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In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation’s quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series—To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)—this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.

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