Published Sep 9, 2002
Study: 40+ hospital drug errors a day
Incorrect prescriptions, messy handwriting among problems
CHICAGO, Sept. 8-More than 40 potentially harmful drug errors daily were found on average in hospitals in a new study, yet another report on a worrisome problem regulators are working to remedy. The most common errors were giving patients medication at the wrong time or not at all, researchers found in a study of 36 hospitals and nursing homes in Colorado and Georgia.
Another report said medical errors contribute to more than 1 million injuries and up to 98,000 deaths annually.
ERRORS OCCURRED in nearly one of five doses in a typical, 300-bed hospital, which translates to about two errors per patient daily. Seven percent of the errors were considered potentially harmful.
The study, which did not evaluate death or injury rates, is published in Sept. 9th's Archives of Internal Medicine. It is based on data collected in 1999.
The rates are similar to those in other reports on drug errors, but the new study highlights a specific point in the process of getting a drug to a patient: "administering errors" made by nurses or other hospital staffers after a doctor has properly prescribed a drug.
'A MAJOR PROBLEM'
Other studies focused on earlier steps, such as doctors prescribing the wrong drug, or pharmacists incorrectly reading a doctor's messy handwriting.
"It's a major problem, not a minor problem, and it doesn't lend itself to an easy solution," said researcher Kenneth Barker, an Auburn University professor of pharmacy care systems.
Barker and colleagues evaluated hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals and nursing facilities. Error rates were similar, regardless of whether an institution was accredited.
The researchers said their findings support implications in a highly publicized 1999 Institute of Medicine report suggesting that the nation's hospitals have "major systems problems." The IOM report said medical errors contribute to more than 1 million injuries and up to 98,000 deaths annually.
81 DAYS OF OBSERVATION
Health-care workers trained for the new study were sent on-site and recorded errors during 81 days of observation. Potentially harmful errors included overdoses and instances when nurses failed to give patients prescribed medication.
The study follows the Joint Commission's recent announcement of six safety standards it will require starting in January to reduce medical errors. The hospital regulatory agency accredits most of the nation's 6,000 hospitals.
The new standards include demanding better methods of preventing drug errors, and hospitals that don't measure up could risk losing accreditation and federal money.
JCAHO says hospitals should use at least two "identifiers"-other than a patient's hospital room number-to ensure that the right drug gets to the right patient.
ID CHECKS SUGGESTED
For example, nurses should check patients' wrist bands and ask them verbally, when possible, to identify themselves, before administering a drug, said Dr. Paul Schyve, JCAHO's senior vice president. Using a room number has been done, but is risky because a patient could be transferred without a nurse's knowledge, Schyve said.
Schyve said the study helps confirm "that there is a problem here and helps guide people to understand where some of those errors lie."
He discounted the study's finding that error rates were similar at accredited hospitals because only 12 such facilities were included. Also, Schyve said, accredited hospitals tend to be larger and handle the sickest patients, thus may be more prone to errors.
Unaccredited hospitals include small, rural facilities that can't afford accrediting regulations, such as having quick access to an anesthesiologist for obstetric patients in case an emergency Caesarean section is needed, Schyve said.
© 2002 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
40+ a day? Is that all? I'd be willing to be the actual number is much higher in many facilities.......
If the joint commission wants to reduce med errors they should also look at things like floating and short staffing. Telling a nurse with 12 patients to take a six step when administering meds will not accomplish much. If you want to add an additional step to passing medications add it to the burdens of a nurse who is taking care of 4 or 5 patients not 12.
The study follows the Joint Commission's recent announcement of six safety standards it will require starting in January to reduce medical errors
I wonder if one of these 6 safety standards is adequate nurse staffing and reducing distractions during med administration. During the last 6 months of my hospital employment I was often given up to 14 patients. I found it humanly impossible to administer meds within the standard hour window. During my exit interview my message to administration was, "I'm not lowering my standards, so I suggest you up yours."
I was wondering also if improving the short staffing was part of JCAHO's plans. Plus the interruptions during the med pass are a joke. I just love when JCAHO comes up with these new standards for pain control, restraint use, and med passes, but won't come up with standards for safe staffing. What a joke.
shannonRN, BSN, RN
i just heard this on the news today...they said something about time being the number one culprit...i think. no kidding! 1)you try to get a med up from pharmacy...it can take up to 3 hours! maybe jcaho should look into having more than one pharmacist in the pharmacy on evenings. and our hospital doesn't even have a pharmacist on midnights!!!! 2)have they ever tried passing meds to 10 patients and getting it all done within that hour time frame? it can almost be physically impossible. and let's not mention checking pulse and bp before giving some of those cardiac meds....some of the nurses on the floor think i'm crazy to check...how do you have time? well, i would much rather spend 5 minutes getting their vitals than having them bottom out because their bp was already too low in the first place... and the list could go on and on...........
JCAHO exists to serve the health care facilities, just as 1.800-DENTIST exists to serve the particular dentists who pay it a fee to recommend THEM. These are both just professional organizations which attempt to create an "in group" of their members who are willing to pay them to join and to be "screened" by them, in exchange for promotional work and the opportunity to claim "special status." Think "country club."
(disclaimer: I am not employed by, own no stock in, and do not profit from 1.800-DENTIST, nor from any of the dentists who pay them. Nor am I a member of any country club.)
If all these errors are occuring then it isnt enough to parrot what all of us have been told "just follow the 5 rs and you wont make a med error".
P_RN, ADN, RN
"Wrong time" CAN be at 0946 instead of the 45 minute window which ended at 0945. Not giving ordered meds CAN be no duloclax suppository at 0900 for a para who wants to wait til bedtime for it.
The pharmacy thingie, the handwriting thingie etc. I believe are just if not more likely causes. And I agree 40 seems kind of low.
Without identifying the parameters by which "errors" were tabulated, we have no idea what these "experts" are talking about. Who knows what motives these people had to arrive at these numbers. Let's follow the money:
From the brief account at the beginning of this thread, it looks as though they were trying to make some kind of case that accreditation by JCAHO means little by finding "med errors" equal in accredited and non-accredited facilities. Which, of course, the JCAHO spokesperson contests. (Not a lot of people who posted to the JCAHO thread here would testify that JCAHO is worth much anyway, so that's not much of a surprise.)
Or they are trying to sell some kind of computerized prescription writer and a computerized pill dispenser (which appears to be the case--here's where the $$$ lies) which supposedly would solve this "problem."
Meanwhile NURSES are supposed to do MORE to make sure these errors don't occur (surprise!) and DOCS are supposed to write more clearly (yeah, right. That's news?)
Doesn't make much sense, at least in the form we read it, as a useful study.
I sounds like they are trying to get the pharmacy companies to make sure they barcode everything (that's going to cost $$$$$)...hospitals will have to invest in more computerization (more $$$$$)....MD's will have to input meds into computer (more $$$ and bad attitude)...pharmacist will have to finish the order in a computer (more $$$ and attitude)...nurses will have to scan their IDs, the patient's armband and then the med to get it administered (more $$$ and attitude). Happens everyday where I work --- the VA. We were mandated two years ago for all VAs to have Bar Code Medicine Administration. It has not been easy or cheap. Training has been ongoing and frustrating. It doesn't work for all situations. And, there are still errors being made because nurses are cleaver and inventive when it comes to getting their work done. Systems have been circumvented and errors still have happen. Right off the bat we had to have the window for administration changed from 1/2 hour on either side of the medicines administration time to 1 hour on either side. So, we really have a two hour window to pass our medications.
It is suppose to be for patient safety but the frustrations and glitches with the program make it easy to try to do a "go around" to get the patient their med on time.
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