In June researchers released findings on the accuracy and validity of a hospital-wide system for reporting medication mistakes. They describe a scourge without pointing fingers, but the report is a reminder that a cure won’t be found without considering the causes. It points to the need for ergonomics, a specialty designed to find and correct underlying problems in systems and the workplace.
Researchers at Johns Hopkins Children’s Center looked at the results of a hospital-wide computer reporting system that chronicles medication errors, most of which do no harm but could be harmful if systems are not corrected. The findings are published in the June issue of Quality & Safety in Healthcare and the June 21 issue of InScribe. They reviewed data collected over 19 months from the voluntary system, which was in use at the Center from 2001 to 2004, analyzing all 1,010 medication errors between July 2001 and January 2003.
Mistakes occurred at every step of the medication process, they reported, and physicians, nurses and pharmacists were equally prone to error.
Of the 1,010 reported errors, 173 were near-misses, which researchers describe as an error that didn’t harm the patient but would likely cause serious harm if it occurred again. In a typical near-miss, the physician prescribes the wrong dose, a pharmacist dispenses the wrong dose, but a nurse catches the error before the dose reaches the patient.
Three-hundred-and-seventy-nine of the 1,010 errors did not reach the patient, 511 reached the patient but no treatment or increased monitoring was required, 103 reached the patient and required increased monitoring, 17 reached the patient and required additional treatment or prolonged hospital stay. None was fatal or caused serious harm.
Nearly one-third were prescribing errors, one-quarter were dispensing errors, 38 percent were administering errors, and 8 percent were documentation errors. Half of all errors occurred in children under 6.
“One of the more interesting findings was that drug-administering errors, such as giving the patient the wrong drug or the wrong dose or at the wrong time, were quite common,” said Christoph Lehmann, M.D., director of clinical information technology at the Children’s Center and one of the authors of the report. “We had focused in the past on ordering errors. This finding made us look for possible interventions on the administration side.”
“Error reporting is only as good as the actual changes that are made as a result of it,” he said. “Identifying and fixing potential medical errors is at the core of the Children’s Center patient safety program.”
Co-author Marlene Miller, M.D., M.Sc., director of quality and safety initiatives for the Center said the goal was to explore the validity of the voluntary system. She stressed that error data are valuable only if consistently monitored for patterns and used to create safety checks that prevent common errors from happening again.
Their observations make a case for looking at all the issues that contribute the errors, another way of describing an ergonomic approach.