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Embrace Technology
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 damaged.

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 bassinet.

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 field day.

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 cancer hospital.

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 and confusion.

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 jet crash.

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.




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