to Stop Prescription Mistakes
August 25, 2003
Commentary. By Eric
Anderson, MD, AMNews contributor. Jan. 27, 2003.
When we were medical students we were innocent, wide-eyed,
hesitant, so we didn't make mistakes. As interns we were indefatigable,
immortal, alphas rampant, so we never made mistakes. As young
doctors we were thoughtful, skilled, very well-trained, so
we couldn't make mistakes. As senior physicians we were confident,
knowledgeable and too experienced to make mistakes.
Yet, we made them.
I thought about this at a hospital staff meeting in the
1970s when an earnest young urologist reported an incident
in another hospital where he ran the quality assurance program.
A physician had just delivered a baby and as he walked with
it to the bassinet he slipped on a floor slick with amniotic
fluid -- and dropped the baby on its head! The baby was brain
That surely subdued a room full of doctors hearing this
story. The immediate reaction in our hospital was to decide
that a physician who had just delivered a baby would stand
still, hand the baby over the mother's abdomen to a nurse
on a dry floor who would then walk with the baby over to the
This protocol wouldn't help the infant in the other hospital
but it would protect other babies from similar catastrophes.
Once we recognized the problem we took steps to deal with
it. And that's logical.
The problem is we don't hear enough about errors and, when
we do, we tend not to believe them. I have trouble, myself,
accepting some of the extrapolated figures from the oft-quoted
studies. It seems preposterous that medical mistakes could
account for 44,000 to 98,000 deaths per year in the United
States, or that the cost of medical errors lies between $17
billion and $29 billion a year.
Whether those numbers are accurate or not, we need to accept
that we're not perfect. We need to hear about all the things
that can and do go wrong. And we need to do something about
them. If we don't, our medical protocols will end up being
written by consumer groups, lawyers and the courts. And every
time something goes terribly wrong, the media will have a
It was unbelievable to read that Betsy A. Lehman, a Boston
Globe health columnist, could die from a mistake while receiving
treatment for breast cancer at the city's most prestigious
And it's equally incredible that from 1997 to 2001 not one
but seven patients died when nitrogen was piped to them instead
of oxygen. The Food and Drug Administration reports that 15
other patients were injured by the same mistake. No wonder
we see headlines such as "More people die from medical
errors than from breast cancer, AIDS or car crashes."
A 1997 study claimed that seven out of 100 hospital patients
experience a preventable medication error. Medication mistakes
have always worried us but, as practicing doctors, most of
us persist with the protocols that continue the problem.
Don Williams, a registered pharmacist with the FDA's Center
for Drug Evaluation and Research, Office of Compliance, has
long talked about the cause of those errors. They range, he
says, from external factors like illegible handwriting, multiple
prescriptions crowded on one blank, poorly transmitted verbal
orders, and look-alike or sound-alike drug names, to internal
pharmacy problems such as telephone interruptions by patients
and doctors, inadequate staffing with heavy workload during
peak periods, and space and design difficulties causing clutter
Some of those troubles are beyond our control but we can
do, must do, better, says Joseph E. Scherger, MD, MPH, dean,
Florida State University College of Medicine in Tallahassee.
Speaking at a recent American Academy of Family Physicians
convention, Dr. Scherger contrasted the way the business world
takes care of its problems. Fifty years ago, the airlines
lost eight times more bags than they do today, despite the
huge increase in traffic -- because, now, bar codes reduce
human error. And when a Mexican jet crashed near Ventura,
Calif., the airlines promptly checked their 1,500 similar
jets and found 12 had the situation that made the Ventura
We need to think that way, says Dr. Scherger. We need to
redesign ourselves. For example, more than 30% of handwritten
prescriptions have an inaccuracy with the date or name of
the patient or the name and strength of the drug.
Speaking to an audience of primary care physicians, Dr.
Scherger, who was declared 1989 Family Physician of the Year
by the AAFP, said, "The future of family practice depends
entirely on the quality of care we deliver. ... In the 21st
century [consumer] expectations have risen so high, unless
we improve we will be replaced."
All this is all very sobering but fortunately we can improve.
We can discuss errors within our offices and ask ourselves
and our staff, "What went wrong?" We can use computers
and handhelds to search for drug interactions, write prescriptions
and transfer the Rx direct to the pharmacy. We can set higher
standards and develop better information systems.
Today's office without information technology is like yesterday's
office without electricity. Technology exists to overrule
human error but to work, it has to be used.
Meanwhile, my colleagues say managed care didn't improve
quality after all, it just got us to run faster. And that
doesn't work with an aging population in our country where
80% of health costs can be attributed to chronic care.
-------------------------------------------------------------------------- Dr. Anderson is a family physician in
a 300-doctor group in San Diego.