The Journal of Clinical

Pharmacology
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Minimizing Medication Errors: Practical Pointers for Prescribers

David M. Benjamin
J. Clin. Pharmacol. 2003; 43; 751
DOI: 10.1177/0091270003255933

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ARTICLE
MINIMIZING MEDICATION ERRORS
BENJAMIN
10.1177/0091270003255933
SYMPOSIUM
Minimizing Medication Errors:
Practical Pointers for Prescribers
S everal years ago, while teaching a group of senior
medical students about medication errors and ad-
verse drug reactions, I asked, “How do you know when
a patient is experiencing an adverse reaction to a drug
as opposed to manifesting pathophysiological signs
and symptoms of their disease state?” There was abject
silence in the room. Not one of the 8 to 10 students had
any answer to offer. I was astonished. Unfortunately,
the problem is even worse than I thought and far more
pervasive than just one classroom, as evidenced by the
following report.
In the spring of 2000, a group of Washington, D.C.,
clinical pharmacologists1 surveyed 105 internal medi-
cine clerkship program directors at U.S. schools of
medicine. The survey inquired into the number of
hours of formal instruction (i.e., lecture) students re-
ceived in evaluating adverse drug events during their
rotation in medicine and what effect the Institute of
Medicine’s (IOM’s) report on medical error had on the
amount of time devoted to instruction in adverse drug
reactions and interactions. Seventy-nine of the pro-
gram directors (75%) responded. Only 16% of pro-
grams had formal lectures on adverse drug reactions
and interactions. Of the program directors, 35% were
unfamiliar with the IOM report. However, all is not
lost: 65% of the program directors stated that they
would devote an average of 1 to 2 hours (range: 1-10) to
formal instruction in adverse drug events if educa-
tional modules were available. A more recent report is-
sued April 8, 2003, by the IOM, titled “Health Profes-
sions Education: A Bridge to Quality,” concluded that
health professionals are not being adequately prepared
to provide the highest quality and safest medical care
possible, and there is insufficient assessment of their
ongoing proficiency. The report recommends that edu-
cators as well as accreditation, licensing, and certifica-
tion organizations ensure that students and profession-
als receive more training in five core areas, including
quality improvement and using information technol-
ogy. Well, fellow clinical pharmacologists, I take great
pleasure in sharing the proceedings of our 2001
Teaching Forum, “Minimizing Medication Errors:
Practical Pointers for Prescribers,” with you for your
DOI: 10.1177/0091270003255933
J Clin Pharmacol 2003;43:751-753
SYMPOSIUM
edification and enjoyment. This mini-symposium of
three papers identifies drugs at high risk for medication
errors and system errors associated with their ordering,
dispensing, and administration. The emphasis is to
provide practical examples from the medical literature,
reliable surveys, and case studies that can empower
health care professionals with the knowledge to im-
prove the quality of their pharmacotherapy and ac-
quaint them with advances in information technology
such as computerized physician order entry (CPOE),
electronic medical records, and bar coding (of patients
and drugs), which can help prevent medication errors.
This symposium provides a very special look at ad-
verse drug reactions and medication errors because it
describes the experiences of the insurance industry
(PHICO data), presents the United States Pharmaco-
peia’s (USP’s) MEDMARX reporting system, summa-
rizes the literature, and presents actual case studies and
descriptive statistics that can be used when teaching
about adverse drug reactions and reducing medication
errors. The same five basic medication errors we recog-
nized decades ago are still occurring: wrong drug,
wrong dose, wrong route, wrong time, and wrong pa-
tient. Practitioners are still unfamiliar with many ad-
verse effects and drug interactions of the drugs they
prescribe, and critical information about their patients
is frequently unavailable at the time of prescribing new
medications.
Moreover, in editing these three papers, I was struck
by the consistency of the findings expressed therein.
Similar classes of medications and errors were identi-
fied by all authors. Antibiotics are still being given to
patients with a history of allergy to them; narcotics are
still being prescribed with too many antihistamines
such as promethazine, diphenhydramine, and
hydroxyzine; follow-up monitoring can be done far
better, both in the hospital and outpatient setting; and
oral and written communication skills can be greatly
improved among health care professionals, especially
physician ordering. Therefore, using these three papers
as a guide, educators can apply the principles of clini-
cal pharmacology to patient care and provide a risk
management approach to recognizing adverse drug re-
actions, reducing medication errors, and improving pa-
tient safety.
751
 BENJAMIN
The recent IOM report and published data1 indicate
that both medical students and experienced primary
care physicians can benefit from contemporary infor-
mation in clinical pharmacology on diagnosing ad-
verse drug reactions and minimizing medication errors
as a part of their focus on patient safety. Moreover, in
addition to improving the quality of pharmaceutical
care, reducing morbidity and mortality, and increasing
patient safety and satisfaction, a recent publication by
Leape et al2 demonstrated the positive impact of clini-
cal pharmacology in reducing the costs associated with
extended hospitalizations and readmissions due to
medication errors. According to various authors, the
cost of an adverse drug event has been estimated at
$2000 to $2500.3,4 However, the cost of a preventable
adverse drug event (i.e., one due to a medication error)
has been estimated at $4685, almost twice as much.5 On
the basis of the $4685 cost, Leape et al have demon-
strated that having a clinical pharmacist make rounds
with physicians and offer suggestions for improving
pharmacotherapy by providing information on dosing,
drug interactions, indications, and alternative medica-
tions at the time of ordering could save an estimated
$270,000 per year in costs of rehospitalization due to
adverse drug reactions in just one intensive care unit.2
According to multicenter studies sponsored by the
Agency for Healthcare Research and Quality (AHRQ),
patients who experienced adverse drug reactions re-
mained in the hospital 8 to 12 days longer than patients
who did not experience an adverse drug reaction
(ADR), and the additional costs of such prolonged hos-
pitalizations were $16,000 to $24,000 more. This
amounts to an estimated cost of $5.6 million/year to
teaching hospitals (see www.ahrq.gov). And that does
not include costs of litigation.
I cannot help but think how ironic it is that the “sug-
gestions for improving pharmacotherapy” that Leape
et al2 published in 1999 were the same types of recom-
mendations my postdoctoral mentor, Daniel Azarnoff,
MD, made during daily clinical pharmacology rounds
30 years ago in Kansas City. Many of us recognize the
teachings and practices of clinical pharmacology in to-
day’s writings and ask ourselves, “Why did it take this
long?” But the positive side is that the time is right to do
more about teaching anyone who will listen how to re-
duce medication errors and improve patient safety.
Innovative federal legislation, such as the Patient
Safety and Quality Improvement Act (H.R. 663), and
legislators in states such as Florida and Oklahoma have
already enacted patient safety laws. Florida now re-
quires “all health care practitioners to complete a two-
hour course related to prevention of error,” and in
2001, Oklahoma was the first state to grant legal privi-
752 • J Clin Pharmacol 2003;43:751-753
lege to medication errors that are reported to the USP,
which has been designated as a patient safety organiza-
tion (PSO). Other states soon will be enacting similar
legislation. Under the pending Patient Safety and Qual-
ity Improvement Act, medication errors reported to a
PSO such as the USP cannot be introduced as evidence
in any legal proceeding (e.g., hearing or trial) against a
health care professional or hospital. The data can be
used only for risk management and quality improve-
ment purposes.
However, despite the compelling nature of new leg-
islation and the collective wisdom of the researchers
and educators cited in this symposium, reducing medi-
cation errors and improving patient safety require
change—changes in behavior and, most important,
changes in communication. After all, the entire process
of medication ordering, dispensing, and administra-
tion is one of communication—communication be-
tween people, communication between people and
machines, and communication between machines and
people. And instituting change is a time-consuming
process that is often met with resistance. Part of that re-
sistance stems from inertia; part stems from xenopho-
bia, the fear of the unknown or the untested; part stems
from egotism in the form of “No agency, administrator,
or computer is going to tell me what to do”; and part
stems from the expense involved in installing a new
computerized electronic medical record system in
your facility or hiring a clinical pharmacist to assist
your physicians with their prescribing decisions.
Change is an arduous process met with great resistance,
even if it is a move in the best direction that leads to im-
proved care and greater patient safety.
Because of the complexity of practicing medicine,
pharmacy, and nursing, especially in the hospital set-
ting, computerization of medical records and inte-
grated medication delivery is the best way to minimize
medication errors and increase patient safety. There is
just too much information to store in your brain.
Relying on memory is a surefire way to prove that hu-
man beings are fallible and experience “mental lapses”
and commit errors, despite our greatest caution and
best intentions. The good news is that the costs of up-
grading your computer system or hiring new clinical
pharmacists to make rounds with your physicians can
pay for themselves by reducing costs associated with
medication errors.2-5 Catching only 25 preventable
medication errors could save an estimated $4685 × 25
or $117,125, enough money to hire a clinical pharma-
cist or make a payment on your new CPOE software.
Moreover, this modest figure of $117,125 is less than
half of the $270,000 savings estimated by Leape et al2 to
occur in just one intensive care unit (ICU) that included
 MINIMIZING MEDICATION ERRORS
clinical pharmacists on rounds with physicians.
Health care is truly a team effort. All members of the
team—MDs, RNs, and PharmDs—must strive to pro-
vide a safety net for our patients and for our colleagues.
Change is coming, but training must begin in schools of
medicine, nursing, and pharmacy and continue into
postgraduate education. Advances in technology such
as bar coding and computerized medical record keep-
ing will definitely improve the systems that health care
professionals use to order, dispense, and administer
medications, but cost-conscious hospital CEOs and fi-
nancial officers must be willing to purchase and install
these systems in their facilities and commit to retrain-
ing their professional staff on the use of these innova-
tive “e-systems.” Software is already available that
will allow an office-based practitioner to write an “e-
prescription” and have it transmitted directly to a
pharmacy previously designated by the patient.
A decade ago, it was fashionable for insurance com-
panies to reduce malpractice premiums for practition-
ers who took special training in risk management or
medication error reduction. Today, much attention is
paid to the bottom line, and many insurance compa-
nies (such as PHICO) have gone out of business. St.
Paul, one of if not the biggest medical negligence writ-
ers, has stopped offering “malpractice” insurance to
practitioners and hospitals. However, with advanced
technology and improved training of health care practi-
tioners, insurance companies should reassess the risks
of insuring facilities and health care personnel who use
electronic ordering, prescribing, and transmission as
well as electronic medical records and decrease their li-
ability insurance premiums since risks of medication
errors and legal liability are reduced by using less error-
prone systems.
Certainly, there is no better discipline than clinical
pharmacology to acquaint the medical community
SYMPOSIUM
with the available resources and help teach practition-
ers the risk management aspects of medication errors. It
is my sincere hope that this special edition of the Jour-
nal of Clinical Pharmacology will contribute to the ef-
forts of our colleagues to teach rational therapeutics
and a safer, more informed use of medications in the
treatment and care of the patients seeking our help.
Now that the practices of clinical pharmacology have
been incorporated into software packages, every practi-
tioner can use them to improve their care. Imagine hav-
ing proper doses, contraindications, drug-drug interac-
tions, and other essential drug safety information
preloaded in your computer, just waiting for you to en-
ter patient information or access it. That day is today.
Despite the problems involved with change, there can
be no doubt that quality improvement costs less than
error making.
David M. Benjamin, PhD, FCP
Chair, Education Committee
Chair, Teaching Forum
American College of Clinical Pharmacology
REFERENCES
1. Rosebraugh CJ, Honig PK, Yasuda SU, et al: Formal education
about medication errors in internal medicine clerkships. JAMA
2001;286:1019-1020.
2. Leape LL, Cullen DJ, Clapp MD, et al: Pharmacist participation on
physician rounds and adverse drug events in the intensive care unit.
JAMA 1999;282:267-270.
3. Bates DW, Spell N, Cullen DJ, et al: The cost of adverse drug events
in hospitalized patients. JAMA 1997;277(4):307-311.
4. Classen DC, Pestotnik SL, Evans RS, et al: Adverse drug events in
hospitalized patients. JAMA 1997;277:301-306.
5. Bates DW, Leape LL, Cullen DJ, et al: Effect of computerized physi-
cian order entry and a team intervention on prevention of serious
medication errors. JAMA 1998;280(15):1311-1316.
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