May 01, 2003
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Implement protocols to prevent, reduce medication errors

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Adopt simple routines to reduce the likelihood of a medication error:

The Office Visit: Review all medications and indications with the patient, including over-the-counter medications, nutritional supplements and herbal drugs, and document the reason the patient is taking these medications.

Review and confirm all drug allergies. Drug allergies should be clearly identified on the patient chart (i.e., a large red sticker with the type of drug allergy on the front of the chart).

Document all medications, indications and dosages in the patient’s chart, and update at each visit. Promote compliance for chronic conditions, such as hypertension and diabetes.

The Prescription: Write prescriptions legibly, clearly and unambiguously. Add drugs to a patient’s regimen based on indications and demonstrated efficacy. As a courtesy, inform the patient of the cost of the drug. On the prescription, fully write out instructions about medication administration. Do not use abbreviations for dosage units or for the name of the drug. Specify the exact dosage strength and the duration of therapy (i.e., “for 7 days”). Avoid the use of terminal zero to the right of the decimal point to minimize 10-fold dosing errors (i.e., use 3 in place of 3.0). Use a zero to the left of a dose that is less than 1 to avoid 10-fold dosing errors (i.e., use 0.3 in place of .3). Use a current drug reference source to verify dosing, side effects and drug-drug and drug-disease interactions.

Patient Communication: When adding a new medicine, tell the patient what it is, how to take it, when to take it, what to expect and how long to take the medication. For example, never assume that the patient will not ingest ocular drops. Explain the possible side effects and specify which side effects should prompt a call to your office. Explain any follow-up instructions and when to return. Provide an opportunity for the patient to ask questions. Send a follow-up letter to the patient’s home summarizing the office visit, any findings, instructions for drug therapy, side effects and your office contact information. With electronic communication and electronically generated letters, these are a minimal drain on time.

Courtesy: It is courteous to inform the patient of the cost of the drug. Letters to other care providers or specialists to which you refer are not only courteous, but can help clarify history, diagnosis and treatment and limit all medical errors, not just those secondary to medications.

There is no therapeutic substitute for common sense: Some conditions should be evaluated so appropriate treatment can be given. These conditions should not be evaluated over the phone.

Continuity of care contributes to good outcomes and requires commitment on the part of the health care provider and the patient. Ignorance is not a defense. Always take the time to check and verify prescriptions, dosing and indications, and document these in the chart. Patients at risk for adverse drug reactions and medication errors include the elderly, the young, those who have multiple or morbid conditions or who are being treated with multiple medications. Conservative dosing (i.e., start low, go slow) with consideration to reduced drug clearance can limit drug toxicity.

Compliance with treatment is reduced with polypharmacy. Adding another drug to treat a side effect of drugs often makes a bad situation worse.

The Institute of Medicine concluded in a 1999 report that each year, medication errors were responsible for 7,000 patient deaths. In other large studies of hospitalized adults, medication errors represent the most frequent cause of injuries from medical care. Approximately 5% of hospitalized adults experience an adverse drug event, and an additional 5% experience a potential adverse drug event (no harm occurred).

Medication errors can be a result of many different mistakes, including:

  • prescribing the incorrect drug;
  • treating with a drug outside of its accepted indication;
  • a delay in treatment;
  • prescribing a drug without consideration to a drug-drug interaction or a drug-disease interaction;
  • illegible handwriting by the health care provider on the chart or on the prescription;
  • poor documentation in the chart;
  • a dose, route or frequency of administration that is inappropriate for the patient;
  • the absence of required therapeutic drug monitoring or other necessary laboratory tests; and
  • a history of drug allergy or a previous reaction to the drug.

Quality of care

Results such as these have spurred many practices, hospitals and academic institutions to closely examine their protocols and implement processes with the goal of reducing the number of medication errors and increasing patient satisfaction, safety and outcome. The environment for improved quality of care is not punitive, but rather one in which health care professionals can learn from the mistakes of others. The Agency for Healthcare Research and Quality is part of the Department of Health and Human Services and has produced a monthly Web-based journal that highlights patient safety lessons taken from real-life cases and provides commentaries, references and examples www.webmm.ahrq.gov.

In an outpatient setting, there are many causes for errors, but simple, consistent steps can greatly reduce the risk of a medication error. Several patient cases will be presented that illustrate “mistakes.” These examples are not to impugn the health care provider or the patient; they are presented as an opportunity for all to learn from the error. Many of these may sound familiar, as they have been discussed in other issues and have been used for educational purposes and for evaluation of quality of care.

Case 1: ocular swelling

A 22-year-old woman went to the emergency department with a chief complaint of eye pain, diplopia and dizziness after having been beaten the previous day with a baseball bat and fists. Physical exam revealed a well-nourished, well-developed woman in moderate distress secondary to pain. Her medical history was unremarkable. Her pupils were equal, round and reactive to light, her fundi were unremarkable, a CT of her head was normal, and her visual acuity was grossly intact.

The patient had significant ocular swelling and bruising bilaterally and multiple bruises on her face, arms and legs. A slit-lamp exam revealed bilateral corneal abrasions and bilateral subconjunctival hemorrhages. The remainder of her physical exam revealed no fractures. She was treated with bilateral polysporin ointment and acetaminophen as needed for pain. Additionally, she was double patched. She received a bus pass and was discharged.

The above case illustrates some important causes of medication errors and the importance of good documentation. Case 1 serves as a reminder of how important good documentation is for charts, including all discharge and follow-up instructions. This patient sustained significant blunt trauma for which she received bilateral eye patches and a bus pass (blind) and acetaminophen for pain. No patient should leave a point of care more impaired than when they arrived, and there were alternatives for double patching. If double patching was necessary, arrangements should have been made with family or friends for safe transport.

While acetaminophen has been shown in clinical trials to be a good analgesic, with these types of injuries, a drug that results in greater analgesia would be indicated. A good choice would have been an acetaminophen/narcotic combination with enough drug to treat pain effectively until the injuries heal or until the next follow-up exam. Nonsteroidal anti-inflammatory drugs would have been relatively contraindicated because of the presence of subconjunctival hemorrhages. In many health care settings, pain is addressed as the fifth vital sign and should always be documented and appropriately treated if necessary.

Case 2: disorientation

A 58-year-old woman with a history of severe hypertension was brought to the emergency department by a family member because she was disoriented and confused. Her initial blood pressure was 250/180 mm Hg, heart rate was 78, respiratory rate was 15 and temperature was 98.4°F. Her medical history was significant for hypertension, which had been treated with benazepril for the past 3 years. Her physical exam revealed bilateral papilledema and lower extremity edema, but was otherwise unremarkable.

The patient had recently seen an advertisement for an over-the-counter arthritis medication, which she had tried without consulting with her primary care provider.

She was treated with IV nicardipine to stabilize her blood pressure, and her mental status began to improve. She was discharged from the emergency department several hours later with instructions to follow up with her primary care provider and to consult before taking any type of over-the-counter agent.

Case 2 is an example of a drug-drug and drug-disease interaction that precipitates an exacerbation of a chronic disease. The patient had treated herself for arthritis pain with an over-the-counter nonsteroidal anti-inflammatory drug (NSAID), which attenuates some antihypertensive medications.

All NSAIDs have the potential to exacerbate hypertension or to cause a hypertensive crisis. This drug-disease interaction is secondary to the effect of NSAIDs to decrease blood flow to the kidney, resulting in elevation of blood pressure and retention of sodium and water by the kidney.

A review of all medications and intervention by counseling the patient by any health care provider would have disclosed this potential for drug-disease interaction. Patients who are being treated for chronic diseases will be more compliant with treatment when there is frequent reinforcement from their health care providers.

Case 3: chronic blepharitis

A 33-year-old man with a history of chronic blepharitis went to his primary care provider because he had thick, crusty exudates on both eyelids. Physical exam revealed a well-nourished, well-developed man with bilateral ocular crusty exudates on his eyelids, swollen red lid margins and loss of most of his lashes. A secondary staphylococcus infection was suspected, and he was given a prescription for cephradine 500 mg three times daily orally, with instructions to follow up in 10 days or sooner if he did not improve or his symptoms became worse.

One hour after the first dose of his antibiotic, he was covered from head to toe in hives, had intense itching and had the sensation that he was being smothered. A friend took him to the local emergency department where he told the emergency department doctor that he had a similar reaction when he took Keflex (cephalexin, Dista) several years ago.

The patient was treated for an acute anaphylactic reaction with epinephrine, diphenhydramine and prednisone. He was given a prescription for prednisone, diphenhydramine, cimetidine and an EpiPen (epinephrine auto-injector, Dey). He was to follow up the next day with his primary care provider or to return to the emergency room if his symptoms became worse.

Allergies should be prominently displayed on the patient’s chart and should be reviewed and updated with each visit. This information would have prevented the anaphylactic reaction. All providers should be cautious and should be knowledgeable in recognizing and treating severe allergic reactions.

Case 4: eye irritation, redness

A 32-year-old man called his primary care provider with a chief complaint of irritation and redness in the right eye. His regular provider was not available, so a prescription for Sodium Sulamyd (sulfacetamide sodium, Schering) eye drops and oral diphenhydramine was called in to his pharmacy. Two days later, the patient called back and reported that he was worse and that his eye was puffy. A new prescription for Pred Forte (prednisolone acetate, Allergan) and levocabastine were called in to his pharmacy. The patient was instructed to discontinue the Sulamid.

One week after the onset of symptoms, the patient went to the emergency department unable to see out of his right eye and with swelling in his left eye. His medical history was otherwise unremarkable. Physical exam revealed a well-nourished, well-developed man in moderate distress secondary to blindness in his right eye. A slit-lamp exam revealed a foreign body in the right eye that had epithelialized and had a rust ring. The patient was referred to the eye clinic for removal of the foreign body. He was then treated with topical antibiotics, a patch on his right eye and 3 days of oral narcotics as needed for pain.

The medication error in this case is attributable to several things. First, an inappropriate agent was prescribed to the patient without being evaluated by the health care provider. Second, there were no follow-up instructions. This error was repeated by filling additional prescriptions over the phone when treatment was determined to be ineffective. There is no therapeutic substitute for common sense; some conditions should not be treated without being evaluated.