Medical Errors : Lessons Learned

by Food and Drug Administration (FDA)

(Page 4 of 4)

ineteenth-century essayist William Ellery Channing defined error as "the discipline through which we advance." Some medical institutions have turned tragic patient safety failures into life-saving lessons.

Department of Veterans Affairs

The VA health-care system is held up in the Institute of Medicine's report on medical errors as a shining success story. The VA has the largest health-care system in the country, by one estimate serving more than 3 million veterans a year at its 172 hospitals and its 1,000-plus outpatient clinics, nursing homes, counseling centers, and other health programs.

The VA counted almost 3,000 errors — some 700 deaths among them — within its health network between June 1997 and December 1998.

Among the major steps the VA has taken to improve its safety record is a new bar-coding system to prevent and track medical errors. Generally, the bar-coding system works this way: ID strips are worn by nurses and patients and attached to medications. Before giving a patient a drug, a nurse scans all three ID strips into a computer, which verifies that the drug is being given correctly and will not cause drug interactions. If the program identifies a potential problem, it flashes a warning. Otherwise, it just keeps a record of the activity.

In a test of the bar-coding technology at two VA hospitals in Kansas, the medication error rate dropped 70 percent over a five-year period.

Other changes at VA facilities include: storing concentrated potassium chloride and other such hazardous medications away from patient care areas, and encouraging cooperation and a focus on correcting the system rather than placing blame on individuals unless they perform negligently or incompetently.

Dana-Farber Cancer Institute

In November 1994, two women got poisonous doses of chemotherapy while being treated for recurrent breast cancer at the prestigious Dana-Farber Cancer Institute in Boston. Boston Globe medical reporter Betsy Lehman, age 39 at the time, died as a result of the error, and the second patient, Maureen Bateman, suffered permanent heart damage and died from cancer several months after the mistake.

Instead of prescribing the daily dose of the powerful anticancer drug cyclophosphamide to be given on each of four days, as planned, the doctor ordered the drug's combined four-day dose so that the total was given to the patients each day.

Since the fatal miscommunication, Dana-Farber has updated its systems to avoid errors. For one thing, the institute has installed a $1.7 million computer system to take over many tasks. Doctors don't hand-write prescriptions anymore, but instead fill out an electronic form with the patient's personal information, as well as the name of the drug, the dose, and the number of days for which the medicine is to be given. The information goes into the institute's computer system, which compares the information with upper dose limits for the drug and other pre-programmed guidelines. If the doctor seems to have made a mistake, the computer signals the error.

Secondly, a nurse checks the information in the computer before ordering the drug from the pharmacy. The pharmacist conducts yet another computerized review for potential drug interactions with other drugs, foods, or the patient's allergies.

After being prepared at the pharmacy, the drug goes next to the nurses' station, where two nurses check the drug's label and the patient's wristband to make sure the right person gets the drug.

Additionally, the cancer center began a system of non-punitive error reporting to encourage open discussion of medical mistakes. The change effectively brought about what the institute has described as a "dramatic increase" in error reporting.

Most-Made Mistakes

The American Hospital Association lists these as some common types of medication errors:

• incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example)
• unavailable drug information (such as lack of up-to-date warnings)
• miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations
• lack of appropriate labeling as a drug is prepared and repackaged into smaller units
• environmental factors, such as lighting, heat, noise, and interruptions, that can distract health professionals from their medical tasks.

About the Author

www.fda.gov
FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.