>> Fortunately, the vast majority
of medication errors never result
in a significant impact for patients.
But, overall, the number of patients
who are injured every year is very significant.
About 1.5 million Americans experience drug-induced injuries
that are preventable every year.
Approximately 1 in every 400 hospitalizations is associated
with a medication error that adversely impacts patient care.
And the economic impact is very large.
If you just look at the added medical care cost associated
with medication errors, it adds about three
to five billion dollars to our health care costs every year.
And that doesn't account for the impact in the loss
in productivity of those people that are affected.
If you add that into the equation, it's in the tens
of billions of dollars.
And some estimate that it's even over $100 billion.
There's a large social impact to that, as well.
First of all, the patients and their families
that experience a medication error,
they often lose their trust in the health care system,
which may make them less likely
to seek medical care when they should.
Also, when they enter into the medical care system again,
they're going to do so with a significant amount of anxiety.
But there's also a big impact on the health care providers
who are involved in a medication error.
They feel a lot of guilt.
There's a loss of confidence in their clinical competency.
Probably the most extreme example of that is a recent case
where a nurse administered a wrong medication,
and it was a very severe outcome for the patient.
And that burden of that was so great
that that nurse attempted suicide.
So there's a huge impact on the health of patients,
economically, sociologically, such that it's imperative
that we really invest significant resources and time
to address the issues of medication safety.
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There's several things that contribute to medication errors.
We know that over 50 percent of medication errors occur
in the area of ordering and transcribing.
So a wrong drug is ordered.
A physician doesn't recognize that there's a contraindication
in that particular patient
or doesn't recognize a drug interaction
or in the transcribing process
between one health professional and another.
About 25 percent of medication errors were due to confusion
of drug names, either written or orally.
We also know that the work environment can be
very important.
A work environment where people are distracted,
where there's a lot
of interruptions is an environment that's prone
to errors.
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One very significant way that we can reduce errors is
to incorporate what's called e-prescribing,
using electronic mechanisms for prescribing drugs.
Right now, less than 20 percent of physicians use e-prescribing,
even though even though 90 percent
of pharmacies are capable
of receiving electronic prescriptions.
And this can reduce errors that come from hearing drug names
that are similar and confusing them, which account
for about 20 percent or more of medication errors.
It also prevents problems that relate
to illegible prescriptions,
whereas another source of confusion.
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Another thing that can be done is
by standardizing equipment and procedures.
As you're probably aware, hospitals utilize pumps
when they administer intravenous medications.
And often a hospital will use a wide variety
of pumps within their system.
So the nurse going from one floor to another
or from one patient to another may have to change the type
of pump they're using.
And that's just a setup for errors to occur.
Standardization of protocols is important.
Sometimes a drug in one unit is prescribed using volume;
in another unit, using mass or weight.
And those types of things, again, confuse people
as they shift from one area of the hospital to another.
Another way that you can reduce medication errors is just
utilizing the full expertise of the entire health care team.
A study in 1999 demonstrated that,
simply by having a pharmacist on the medical rounds
in a hospital, can reduce by 66 percent the number
of medication order errors.
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Humans are going to make mistakes.
And what we need to do is we need to create a system
where a human mistake doesn't result in a human tragedy.
We need to look at the health care system
from a holistic approach and recognize that,
when errors occur, whether they're medication errors
or other medical errors, the objective should be not to find
who do we blame but to find the problem in the system
and address it from a systems approach, much as we do
in the airline industry.
We want to have enough safeguards in place
that a single human error doesn't get transmitted
throughout the whole system and, ultimately,
then, reach the patient.
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We recently found that, every time a patient is handed off
from one area in a hospital to another, we see an increase
in the number of errors.
So a patient coming from --
as an outpatient and coming into the emergency room,
there's a certain percentage of medication errors.
Now, when you take and move that patient from the emergency room
to the critical care unit,
the number of errors actually increased.
Going from the critical care unit to the step-down unit,
there are additional errors; and then down to a regular unit.
So this transferring of patients from one unit
to another is a key area that we need to work on.
Now we know that's a major source of errors.
We need to identify strategies to prevent those errors.
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Another area of research is looking
at the issue of health literacy .
If you look at the outpatient population of medication use,
much of it is self-directed.
Patients have to be able to understand labels
in over-the-counter medication
and also prescription medications.
And we make an assumption that people can understand them.
There's a lot of research now being taken
as how do we best structure physically those labels
so that people can read them appropriately and pick
up the right messages that they need to
and prevent confusion between medications.
Many patients today are taking five and four medications.
We need to make sure
that they're taking each one appropriately at the right time.
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As we see the baby boomers coming to senior citizen age
and increased need for health care,
we're going to see a greater stress
on our health care system.
In addition, as a nation, we're becoming more aware
of the underserved population: people who need health care but,
for financial or other reasons, don't have access to it.
And, as we bring those individuals
into the health care system,
the volume of patients being treated is going to increase.
And that, again, is a setup for errors, medical errors and,
specifically, medication errors.
Also, there's going to be greater complexity
in the drugs that are used.
We're learning more and more
about how genetics influence the way
that people respond to drugs.
And we already have some drugs where, before they're used,
there's a genetic test.
And that genetic test maybe determine whether the drug will
be a right choice for that patient,
or the genetic test may determine how much
of that drug should be given.
So the complexity of deciding what drug to what patient
at what dose is increasing as we learn more and more
about how patients respond.
And those types of things are going
to require more highly trained health care providers to be able
to oversee that system and a much more careful system
that has the right checks and balances
to prevent errors from occurring.
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