Thursday, March 26, 2009

Medication errors - no one wants to find out...

News report today of a medication error that came to light only because the patient's family made it public. Honest mistake by a sincere, decent doctor. But potentially tragic.

Medication errors occur much more commonly than the public is aware of. (I personally heard of recent incident in a local major hospital.) A recent report (2006) by the National Academies of Science highlighted this problem and estimated that medication errors harm at least 1.5 million people every year in the US. The medical costs in managing these errors amount to some US$3.5 billion. Awareness and simple solutions can prevent many of these problems.

Unfortunately no one locally seems to be interested. The hospitals don't want to know. And obviously do not have any means to track this problem. The Ministry of Health show no interest in auditing this problem and is quite content to let the hospitals manage the problem by sweeping everything under the carpet.

See no evil, hear no evil - and no evil shall be spoken, seems to be the motto.


Shanz said...


I think it's not that nobody is interested in medication errors. Most medication errors are recorded in an electronic system where only selected hospital staff can assess. Most are "near-misses", some are sentinel events. It is not "publicised" or "audited" by external party because it's sensitive information. Most sentinel events usually involve a root cause analysis to find out the real cause. (just FYI)

gigamole said...

You are right.

And to a large extent that creates a sense that no one really knows and no one really cares. You seem to suggest that medication errors are accurately captured on the electronic medical records, but how are they actually captured? What actually flags them out? This will critically depend on how the hospital sets the sensitivity of the system to 'capture' such errors. Does it only capture the most obvious ones? And what are the sentinel events you refer to? Death? Patient complaints? To what extent does it depend on the willingness of the staff to record such errors into the hospital EMR?

What's the assurance that the privileged 'selected' hospital staff actually looks at the data and reports on this? Does the hospital have an internal audit of this process?

The recent report highlighted from the National Academies of Science suggests a much higher prevalence of such events than previously recognised, so it really depends on how sensitized the hospital wants to be in improving on its track record of medication errors.

Shanz said...

I think you pictured a scenerio in which the computer "picks" up the mistake. In actual fact, it's when the mistake is picked up, and the staff/supervisor will report it in this electronic hazard occurrence report. This can be at any stage of the medication "delivery", i.e. prescribing, transcribing, picking, checking, administration. "Sentinel events" are those which have already reached the patient's end, i.e. not picked out along the way, e.g. wrong dose administered. In this such a reporting system, it is inevitable that there will be under-reporting.

When a root cause analysis is done to address an event, it should pick up direct/indirect causes of the medication errors, e.g. staff too tired, lighting too dim, sound-alike medicine names, look-alike medicines. Of course, things like staff too tired cannot be easily solved because the management will look into the manpower which cannot be solved overnight. However, things like sound-alike medicine can be solved if the staff manage to convince the vendor to change the packaging of the medicine.

I'm just sharing what I know so that the public will not go away thinking that hospitals are trying to avoid looking at this problem. This problem is existent long before and it's still a problem all hospital staff are trying to prevent now. It is a fact healthcare is dangerous, healthcare has too little money to invest in better systems, healthcare is too dependent on human and thus human errors. But every healthcare staff in the hospital who are responsible for dealing with medicine, are working out in steps to work within their means to make it safer, e.g. compulsory to double check for every stage of the "delivery".

How to "wipe out" medication errors 100%? I dun think anybody have a clue as medication administration is still very dependent on humans and very primitive. We all know automation with careful barriers is the answer, but it's the *chiing chiing* $$$...

long long post...

gigamole said...

Thank you so much for your 'long long post'. Believe me when I say I am so heartened and encouraged by your explanation. I have been through the backrooms and corridors enough to know that there are very few who will take time off their 'busy-ness' to try and get an insight into some of these problems as you have highlighted.

I did not intend in my post to devalue the work that you and your colleagues are trying to do with regards to this issue. If I sounded that way, please forgive me. My intention was to highlight this problem as it exists in its 'invisible state'.

It is, regardless of the efforts put in by such as yourself, pretty much an 'invisible disease'. The public does not see it. The hospitals hide this information behind 'sensitivity walls'. While some attempt is made at hospital management committees to deal with this problem, solution providers remain relatively poorly resourced. Unfortunately solutions tend to generate numbers in the wrong column of the hospital balance sheets. Until and unless the hospitals appreciate that the public is aware of these problems and are expectant that they make a better attempt to deal with this problem, it is very easy to continue sweeping it under the carpet.

Many of the problems have root causes that are related to human factors issues be they tiredness, lighting, poor scheduling of work flow, communication, teamwork etc. These require effort, time and resources to resolve. We all know that if errors can be minimized it will not just be better for everyone, but will eventually result in major cost savings. The problem for the hospital medication teams is that the cost savings get reflected in some other departments cost centre.

I don't think we can 100% eliminate medication errors, but we can at least do our best to minimize it. The question is, how convinced are we that the hospitals are doing all as much as they can to minimize the risks?

Thank you Shanz. Keep the faith!