April 08, 2003 Volume 39 Issue 14

Medication errors more likely to reach patients in ER setting

Fast-paced ER environment lacks pharmacy to help intercept mistakes

By Nancy Deutsch

ROCKVILLE, MD. – An anonymous medication error reporting program has found that while most drug blunders made in hospital are caught before reaching the patient, many mistakes in the emergency room cause harm before being recognized.

While the news is not startling, it may be a revelation to those who work in the ER, said Dr. Diane Cousins (PhD), a pharmacist and vice-president of the United States Pharmacopeia (USP) Centre for the Advancement of Patient Safety, which recently issued its third annual report—an analysis of data from 386 U.S. hospitals.

Emergency departments are organized to deliver prompt, life-sustaining care in dynamic situations and therefore they function differently from other patient care areas. In emergency departments, more errors reached patients than elsewhere, and in this survey, 7.6% of the errors in ERs resulted in patient harm. The errors arose mostly from prescribing or administration mistakes. One of the reasons for this was that the usual pharmacy oversight of prescriptions was absent and so the opportunity to intercept errors was missing, she suggested.

USP is a non-governmental organization that provides an Internet-accessible way for personnel who work in participating hospitals to anonymously input data on errors that are discovered. The average cost to participate is $3,500 US per hospital per year, and about 600 of the 5,000 hospitals in the United States take part, Dr. Cousins said.

For this price, those who work at the participating hospitals can see what types of errors occur most frequently, and can use the information to develop ways to combat the noted problems.

The new report lists errors reported in 2001, the last year for which current information is available. In that year, 105,603 errors were documented, of which 2,063 (about 2%) were ER-related.

Dr. Stephen Schenkel, an emergency medicine resident at the University of Michigan in Ann Arbor, said he found that percentage surprisingly low. "We see the sickest patients and are under significant time pressures, which all contribute to the potential for harm," he pointed out.

He was most surprised by the high total number of errors. "Using voluntary reporting, they got enormous numbers." But most must have been reported by pharmacists, he noted, since few doctors have time to sit down and enter an error they may have made.

Twenty-three per cent of the medication errors in the ER were intercepted before reaching patients, compared to 39% in other areas of the hospital. Of all medication errors that reached the patient, 2.4% were harmful or fatal.

There were 14 fatalities reported due to medical errors in 2001. This was a significant increase from the three reported a year earlier.

Omission errors were most frequently reported as the type of error occurring in other areas of the hospital (forgotten doses). In the ER, improper dosing was most common. The medications most frequently involved in errors were heparin, insulin, potassium chloride, morphine and albuterol (salbutamol in Canada).

Many of these medications involve "complex procedures and protocols," which may help explain why more errors occur with these medications, Dr. Cousins said.

They are also highly variable in terms of dosing, noted Dr. Schenkel.

Reasons for making medication errors included being distracted and having a heavy workload, according to the report.

However, "a lot of these things are repeating year to year," Dr. Cousins noted.

More errors could be averted if patients ask about what they are given, she said. "If they're alert enough to ask: 'What is that you're giving me?' " this could lead to a mistake being avoided, she said, because it may cause the health-care professional to think more about the drug being given.

She said that at times the patient has already received the drug from another member of the health-care team and has been able to say so, avoiding double-dosing.

It's important for doctors to think of how a medication error could occur in the ER, or how a drug-related error could be the reason for the ER admission in the first place.

She recalled one reported incident. A patient made repeated ER visits due to problems controlling his asthma. One physician who saw him asked him to demonstrate how he took his inhaler, when and at what dose. All were correct, but the patient returned to the ER yet again. Finally, the patient was told to bring the medication in at the next visit. It turned out the patient was given the wrong drug at the pharmacy.

"Physicians need to put that in their repertoire of possibilities," she said. "They need to be cognizant that these errors do occur."

Dr. Schenkel said there have been changes to the ER recently that should help to reduce errors. More doctors in the emergency department are trained specifically to work there, he said.

It's also helpful that pharmacists pre-prepare doses of medications to be given in other areas of the hospital. Unfortunately, that kind of system doesn't work in the ER, he said.