Many Incorrect Drugs Given to Colorado Hospital Patients, Study Says

Home Health Columnist / Guide · Sep 13, 2002

denver post...09/10/2002

http://webpublisher.lexisnexis.com/index.asp?layout=story&gid=1730000973&did=46rb-75j0-01cv-h350-00000-00&cid=1920004392&b=s

by marsha austin

one out of every five drugs given to patients in colorado hospitals and nursing homes is given in error, according to research published monday in a journal sponsored by the american medical association.

in 1999, researchers followed nurses on medication rounds at 16 hospitals and eight nursing homes in denver, boulder and greeley and witnessed nurses giving drugs at the wrong time or not at all, administering the wrong dosage and sometimes giving patients the wrong drug.

"error is common, so common that just telling nurses to be more careful is not the answer," said dr. ginette pepper, a professor at the university of colorado school of nursing and one of the new study's authors.

eighteen hospitals and nursing homes in georgia were also included in the study, which appears in this month's sue of archives of internal medicine.

colorado hospitals had more than twice as many medication errors as georgia hospitals, researchers found. in colorado, 22.75 percent of drug doses were administered improperly, while in participating georgia hospitals medication errors occurred 11.5 percent of the time.

physicians who reviewed the medication errors determined that 7 percent, or about 40 doses of drugs a day in a 300-bed hospital, were serious enough to cause death or serious harm to the patient.

the higher instance of drug-related errors in colorado may be because hospitals studied here care for more seriously ill and injured patients who can place heavy demands on nurses, pepper said.

one of the biggest contributors to nurse error is distraction and interruption while filling a drug order, she said.

the research comes three years after the institute of medicine reported that an estimated 98,000 americans die from medical errors each year. that report also found 710,000 drug-related errors per year.

the iom's now infamous report on medical errors focused heavily on physician prescription errors in causing patient deaths. the new study builds on that information by taking a closer look at what happens between the time a nurse gets a doctor's drug order and when he or she gives, or forgets to give, that drug to the patient.

"nurses are the last line of defense in prescription drug administration," pepper said. "there's nobody after the nurse except the patient." hospital names were not published in the report, and none of colorado's major hospital systems could confirm whether they were part of the study. but statistically, the research would include a good number of the denver metro area's 12 private, full-service hospitals. university of colorado hospital did not participate, said pepper.

colorado's hospital industry emphasized monday that much has been done in recent years to prevent medication errors.

that so many hospitals agreed to participate in the study, titled "medication errors observed in 36 health care facilities," underscores hospitals' commitment to share information about mistakes in the hopes of eliminating unnecessary harm to patients, said peg o'keefe, colorado health and hospital spokeswoman.

"the better we understand how errors occur, the better we are able to prevent them from happening again," she said.

the new study could spur denver-area hospitals to invest in technological tools such as patient bar code bracelets and computerized drug cabinets, said hospital executives.

at porter adventist hospital in denver, nurses are encouraged to report "near misses." "we don't penalize them, we give them a candy bar," said dale hand, porter hospital's director of pharmacy.

hand said the hospital wants to encourage nurses to tell hospital administrators about mistakes, not cover them up. such open-door policies are the only way hospitals can learn enough to reduce errors, he said.

and the hospital already has computerized drug cabinets that nurses can only open after a physician's order -- sent electronically -- is verified by a hospital pharmacist who unlocks the proper cabinet drawer.

"it's not perfect, they could still grab two pills instead of one," hand said.

but it's helping, he said.

porter is also seriously considering putting bar codes, like the ones that tell grocery store clerks how much a box of cereal costs, on patient bracelets. there would be a corresponding bar code on the patient's drug. a nurse scans the patient's bracelet and then scans the drug. if it's the wrong drug or the wrong dose, an alarm sounds.

veterans affairs medical center in denver is already using this technology, and several private hospitals are piloting the system.

pepper is just beginning a three-year study of the leading causes of nurse-related medical errors -- such as noise, light, interruptions -- and how to create working environments that foster more accuracy.

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