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 one
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 Edit medical care costs
associated with medication errors it is
about three to five billion dollars to
her healthcare costs every year and that
doesn't account for the impact and the
loss of 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 a
hundred billion dollars there's a large
social impact of that as well first of
all the patients and their families that
experience a medication error they often
lose their trust in the healthcare
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 nervous administered a wrong
medication and it was very severe
outcome for the patient and that burden
of that was so great 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
there are several things that country
stationers we know that over fifty
percent of medication errors occur in
the area of ordering and transcribing so
wrong drug is ordered 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
another about twenty-five percent of
medication errors 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
one very significant way that we can
reduce errors is to incorporate what's
called be prescribing using electronic
mechanisms for prescribing drugs right
now less than twenty percent of
physicians use be prescribing even
though over ninety 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 twenty percent or more
of medication errors it also prevents
problems that relate to illegible
prescriptions where is another source of
confusion
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 use a wide variety of pumps
within their system so the nurse going
from one floor to another 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 in those types of
things again confused people as they
shift from one near the hospital to
another another way that you can reduce
medication errors is utilizing the full
expertise of the entire healthcare team
a study in 1999 demonstrated that simply
by having a pharmacist on the medical
rounds in a hospital can reduce by
sixty-six percent the number of
medication order errors
that 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 human tragedy we need
to look at the healthcare system from a
holistic approach and recognize that
when errors occur whether the medication
errors or other medical errors the
objective should be not defined who do
we blame but define the problem in this
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
we recently found that every time a
patient is handed off from one area
hospital to another we see an increase
in the number of errors so patient
coming from as an outpatient coming into
the emergency room there's a certain
percentage of medication errors now when
you take a move that patient from the
emergency room to the critical care unit
the number is 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
another area of research is looking at
these
literacy if you look at the out patient
population medication use much of it is
self-directed patients have to be able
to understand labels and
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 the taking each one appropriately
at the right time
as we see the baby boomers
senior citizen age and increased need
for healthcare we're going to see a
greater stress on our health care system
in addition as a nation we are 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 healthcare 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 there used as a
genetic test and that genetic tests
maybe determine whether the drug will be
a right choice for that patient with
Jeanette has may determine how much of
that drug should be given so the
complexity of deciding what drug to what
patient at what does is increasing as we
learn more and more about how patients
respond and those types of things are
going to require more highly trained
healthcare 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