First, Do No Harm, Errors in Medicine
There are more ways to give medication to a patient than ever were thought possible. With all these advances come a greater number of chances to make errors of omission, or commission.
A well-known medical aphorism is, “first, do no harm.” No one would argue with those words. But there are many ways that harm occurs – and errors also occur without harm being done.
Back when there were fewer medications, fewer procedures, fewer tests, and fewer ways to do things, error corrections were easily made, omission errors were readily avoided and the possibility of dosage errors occurred less frequently. Currently there are innumerable medications of more types than ever were imagined. More procedures exist than ever were envisioned 50 years ago. There are more ways to give medication to a patient than ever were thought possible. With all these advances come a greater number of chances to make errors of omission, or commission.
These advances have enhanced the public’s expectations for favorable outcomes. With rare exceptions, everyone expects an excellent result. If the possibility of a poor result is not predicted up front, a good outcome is seen as the only possible outcome.
Those in the health care field know that this ever-idealistic outlook is unrealistic, but lawyers advertise that any expectation not met will be assuaged with financial settlements, and that there will be no charge if no money is collected. This approach has raised havoc with the medical malpractice situation in America. Some physicians are leaving practice as soon as possible; others are moving to areas where the insurance premiums are not outrageous, and still others are abandoning needed high-risk specialties to pursue something else.
But errors remain. Hospitals are discovering that finding and correcting potential sources of errors results in fewer mistakes, lower costs, less hospitalized days resulting from errors, fewer distraught patients, and a happier staff.
Studies of the system
Many people have studied adverse effects in the health care setting, as well as how to implement changes to prevent untoward outcomes. In general, they talk about system analysis, and root cause analysis.
System analysis has to do with how the whole system works or doesn’t work to help us do things. For example, does the ordering system allow us to obtain drugs or equipment fast enough? Does our distribution system allow the right drugs to get to the right places at the right time? In other words, do the pieces of the system contribute to the cause or the prevention of errors?
In root cause analysis, the question is what were the immediate causes for the error? Was it a poor label on the drug? Was the wrong patient’s name on the drug? Did someone forget?
There can be many sources of error, and/or small events contributing to error, from bad handwriting and faulty prescription reading to putting the right medication in the wrong patient’s bottle, to going into the wrong room to administer the medication.
Those few institutions with installed computer systems and software to address these problems have reported improvements in the error rate. While no system is perfect, we agree that some improvement is better than no improvement. Cooperating institutions send error reports to an analyzing unit that in turn compiles reports and sends them back with a comparison with all other results. These comparisons plus discussions among institutions point the way for system changes to reduce error, enhance efficiency and sometimes indicate completely new ways to get the job done.
In general, various elements of the Federal government, state agencies, the AMA, evaluation agencies, insurance companies, and non-profit health organizations all have a hand in looking at these problems. This approach is inefficient. It will cost more money than any hospital can afford, and therefore it is unrealistic. Everyone is attempting to bring these approaches into line so that costs become reasonable and the needed changes become real.
Medication errors have been regarded as one of the most significant concerns since the Institute of Medicine reported that medical errors of all kinds cost 98,000 Americans’ lives annually, and that medication-related errors account for 7,000 lives. Since that report, various regional medication error reduction initiatives have begun, some with concrete results.
Bar coding helps accuracy
Accrediting and regulating agencies have provided for the development and use of medication bar coding. The effect of medication bar coding is to eliminate medication identification error (preventing name and dosage confusion), eliminate administration errors (the right patient gets the correct medication and dosages are not omitted accidentally) and, by getting the pharmacy involved, the appropriate mode of administering the medication used is assured.
The bar-coding systems cost $1-5 million in start-up costs and $0.5-1 million yearly to maintain. This cost is no small burden, especially for smaller hospitals.
Also included in automation of medication administration is computerized order entry, which requires institution-wide computerization of records. Again, the downside is cost. The upside is elimination of writing and transcription errors and automatic error checking including medication compatibility and a check for patient allergies.
Hospital grouping cuts down on errors
Where hospitals have grouped together to report errors and to evaluate how effective the error collection and reporting systems are, local medication error reporting groups have found where most of the medication errors lie, and have begun to make changes to reduce future mistakes. They discovered that four classes of drugs were responsible for nearly 45% of all errors resulting in serious harm. This kind of information can lead to early and effective error correction.
Very often, the error correction involves using patient education to eliminate inappropriate medication use, doctor education to reduce dangerous abbreviation use, and nursing education to enhance appropriate medication timing. Safety checklists, especially for medication pumps, are an especially useful safeguard.
Even if an error is corrected, if the outcome has a significantly adverse effect on the patient, the long-term emotional and psychological impacts may be devastating to the family. Physicians and other professional staff react with great emotion to adverse results because, as a group, they also react in a very personal way to a less than expected outcome. They perceive it as failure; this attitude is unacceptable, when the first goal is to do no harm.
Can we expect improvement?
No one is quite sure how big the problem is, although we are quite sure it is not a small problem. What is the answer to “how bad is bad?” Should we count an error that is caught before it is made? Should we count one that does not harm anyone?z
One thing is certain: no system is perfect. There is no such thing as an error-free performance. We hope that somewhere in our future a mechanism that is financially viable will be found so we can address both systemic and root causes for error.
The patient’s role
Much has been written about the doctor’s role: he/she should speak more slowly, using non-technical language, repeat what is said, provide printed information, ensure follow-up. The patient should be reminded about what must be done next.
But what should the patient provide? How about the following: an accurate history, not withholding information; thoughtful answers, no guesses, complete family history, accurate current medication list including non-prescription items from vitamins to herbal medicines, along with how and when they are taken…and visits to any other practitioners.
The patient also should have a list of questions to ask about his/her condition, and come armed with paper and pen to write down the answers. Those answers should be shared with the patient’s partner once back home.
The biggest defense against error requires the doctor having complete and accurate information on which to base advice and recommendations. In addition, when the patient has complete and accurate information, he/she is much less likely to make mistakes carrying out treatment.
The Internet is a big source of information, both good and bad. The doctor may be able to help sort it out, too.
But – completely error-free medicine? No way. Not as long as fallible human beings are involved.
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"First, Do No Harm, Errors in Medicine"
C. Robert Meloni, M.D., FACP, FACE, is board certified in both internal medicine and endocrinology. He is a graduate of Harvard College (BS), Georgetown University (MS), and New York Medical College (MD). The former Chairman and President of the Nort...