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Read this today and thought you might be interested Hugs, Deborah aka Tenacity --------------------------------------------------------------- Medication Errors Rampant in Hospitals But Changes Are Underway to Ensure Accuracy, Safety By Jeanie Davis Sept.10, 2002 -- Too often, hospital patients receive their medication at the wrong time -- or don't get the right dose, a new study shows. It's news that hospital officials are having difficulty swallowing. "Every hospital I've ever been in, people believe one error is one too many," says Peg O'Keefe, spokesperson for the Colorado Health and Hospital Association, based in Denver. "We continue to focus on eliminating mistakes ... I've seen it make a difference." Hospitals are working hard to make improvements in their systems -- to ensure accuracy and reduce errors, says O'Keefe and other industry leaders. Two examples: bar coding that matches patient IDs with medications and computerized order-entry systems in pharmacies. The issue drew national attention two years ago, when a report from the Institute of Medicine came out with similar findings. That study showed that 56% of medication errors were due to prescribing errors, and 44% involved administration at the hospital. Since then, hospitals have taken action not reflected in the current study, O'Keefe tells WebMD. The current study involved 36 hospitals and skilled nursing facilities -- all in the Atlanta and Denver-Boulder-Greeley, Colorado areas. Researchers point out that 26 hospitals they originally contacted declined to participate, and were replaced by other randomly selected institutions. "Medication errors were common," says lead researcher Kenneth N. Barker, PhD, director of Auburn University's Center for Pharmacy Operations Design. His study is published in the Sept. 9 issue of Archives of Internal Medicine. Researchers analyzed medication doses given (or omitted) during a one- to four-day period by nurses on units administering high volumes of medication. A pharmacist or nurse -- trained as an observer -- went with the nurse as she prepared the medication and watched her give it to the patient. The observer then recorded the activity, without knowing the accuracy of the medication or the dosage. Later that same day, the observer reviewed the patient's charts for discrepancies, which were tallied as errors. The results: 19% of the 3,216 doses were in error, according to the study. In 43% of errors, dosage was given at the wrong time In 30% of errors, the dosage was not given at all In 17% of errors, the wrong dosage was given In 4% of errors, an unauthorized drug was given. Medication errors were common -- nearly one in 5 doses in the typical hospital and skilled nursing facility, Barker reports. A panel of three doctors determined that the percentage of errors that were potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. Barker's report is a "snapshot" of healthcare as it existed three years ago -- not as it is now, says O'Keefe. Hospitals have begun making a number of improvements since then, which Barker's study fails to capture, she tells WebMD. New computerized order-entry systems in hospital pharmacies minimize mistakes that come from reading physician handwriting, she says. The system sends an "alert" message, asks questions, prompts the pharmacist to review and question the prescription's accuracy. Each patient now wears ID badges with bar codes -- which can be matched with their medications, to ensure accuracy. "Hospitalists" are medical doctors that are now based in many critical care hospital units; they track and manage patient care in that unit. "We're seeing it more and more -- a physician on site to manage care of patients rather than nurses," says O'Keefe. "It provides better continuity of care." Healthcare facilities are focusing less on blame -- and more on safety, she adds. "If a mistake or near-mistake happens, the person is encouraged to step forward, describe it, and instead of blaming them, we look into how the mistake happened, what can be done to prevent it from happening again. It helps prompt more people to come forward. I've seen it make a difference." "I'm proud of our hospitals for opening their doors," O'Keefe tells WebMD. "This is a voluntary study, and our hospitals are continuing to say we're inviting people in to learn what we can, because you can't get better unless you understand what's happening." Barker's study is "a useful reminder of how we're doing," says Kasey K. Thompson, PharmD, director of the Center on Patient Safety at the American Society of Health-System Pharmacists in Bethesda, Md. "It's very clear that this isn't an attempt to say we have a bunch of bad nurses out there," Thompson tells WebMD. "It's looking at expected failures from poorly designed systems of care in hospitals." "Everyone makes mistakes," he adds. "This study tells us there are things we need to do to help our practitioners do better rather than just lay blame and punish. In the last three years, there's been a lot of positive work done in hospitals to improve medication systems, to minimize preventable patient harm. There is a lot of good going on out there." Thompson's advice to family members and patients: "Be vigilant. Ask questions, have a family member ask the person with the drug, 'what is that and who is it intended for?' and make sure they verify your name. If you have questions about drug therapy, ask your pharmacist, ask your doctor. Vigilance is still extremely important." © 2002 WebMD Inc. 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