James G Anderson
Professor of Medical Sociology
Department of Sociology & Anthropology
West Lafayette, IN
Fellow, American College of Medical Informatics
Medication-related errors are frequent in healthcare delivery. It has been estimated that, in the USA, adverse drug events (ADEs) occur in two out of every 100 patients admitted to the hospital, increasing the cost of hospitalisation by $4,700 (euro 3,893).(1) The increased costs for a 700-bed hospital due to ADEs were estimated to be $2.8 million (euro 2.3m) annually. ADEs also occur among outpatients. One study found a rate of 5.5 ADEs per 100 patients who visited primary care physicians in the Boston (MA, USA) area.(2)
The true rate of medication-related errors is difficult to ascertain since most errors are not reported. Hospitals generally rely on voluntary reporting, which may result in the detection and reporting of as little as 10% of ADEs.(3) For example, a study of hospital units estimated on the basis of direct observations that as many as 51,200 errors would have occurred in dispensing and administering medications over a period of 59,470 patient-days. However, only 36 errors were reported on incident reports, and 84 errors were reported on anonymous questionnaires.(4)
Medical errors are usually treated as individual mistakes or failings and are punished largely by peer sanctions. At the same time there is growing realisation that the majority of medical errors result from poorly designed healthcare systems. Preventing and reducing medical errors that result in ADEs requires implementation of IT. Several studies that have demonstrated how IT can be used to detect and prevent medication errors and ADEs are described below.
Detection of ADEs using IT
Computerised screening systems can be developed to identify potential ADEs. These systems generally screen data such as ICD-9 codes, pharmacy and laboratory data and free text. In most instances, chart review is used to verify that the event detected by the automated system involved a potential or actual ADE.(5)
For example, a computerised system at LDS Hospital in Salt Lake City (Utah, USA) was programmed to generate a daily list of potential ADEs from data contained in an integrated hospital information system.(6) Potential ADEs were indicated by sudden medication stop orders, ordering of antidotes and abnormal laboratory values. The medical records of all patients on the list for potential ADEs were reviewed by a clinical pharmacist. Over an 18-month period, nine ADEs were identified by the traditional reporting system, while the automated system detected 631 of 731 verified ADEs. The success of the surveillance system led to improvements in drug ordering and delivery, which averted a significant number of potential ADEs.(7)
Most of the information systems used to detect ADEs have been developed and implemented in inpatient hospital settings. One system, developed to detect ADEs in an ambulatory setting, was programmed to search for ICD-9 codes that had been found to be associated with ADEs.(2) A database containing the patient’s medication and drug allergy lists was also scanned. A third approach to identifying ADEs was computer-event monitoring. Rules were developed to identify new medication orders, abnormal laboratory results and changes in laboratory values, which are frequently associated with ADEs. Finally, the Micromedex M(2)D(2) medical data dictionary was used to electronically examine visit notes. For each incident identified, a chart review was used to ascertain whether an ADE had actually occurred. Over a one-year period, 23,064 electronic patient records were reviewed and 864 ADEs were identified. Text searching identified 91% of the ADEs: 6% were identified from the allergy records; event monitoring identified 3%; and ICD-9 codes found only 0.3% of the ADEs.
Reducing drug-related errors using IT
Existing IT has been shown to reduce errors and resulting adverse effects on patients. One example is a computerised physician order entry implemented (CPOE) at Brigham and Women’s Hospital in Boston.(8,9) Physicians were required to enter medication orders into the system. Relevant laboratory results were displayed when the physician entered orders. The system checked for allergies and drug–drug interactions. The computerised systems reduced the incidence of preventable ADEs by 17%, saving the hospital an estimated $489,000 (euro 455.036) per year. Even greater improvements in patient safety were realised when a clinical pharmacist participated in patient rounds on the intensive care units at the hospital.
Computerised alerting systems have also been shown to decrease error rates, delays in treatment, hospital length of stay and costs.(10) The Health Evaluation through Logical Processing (HELP) system at LDS Hospital in Salt Lake City automatically identifies patients who are at risk for ADEs by continuously monitoring electronically stored patient data. When potential ADEs are detected, the system alerts hospital staff to take action to prevent harm to the patient.
However, studies such as the one reported by the Institute for Safe Medication Practices(11) suggest that piecemeal implementation of information systems may fail to detect and prevent errors. Anderson and colleagues(12) developed a simulation model to evaluate the capability of IT to detect and to prevent ADEs in hospitals. The model was used to estimate ADE rates and associated hospital costs based on five IT applications, namely: provision of computer-based drug information at the prescribing stage; physician computer order entry; a unit dosing system in the pharmacy; an automated medication dispensing system; and a comprehensive information system for medication delivery. Individual IT applications would reduce ADEs by 5–13%. In comparison, the implementation of a comprehensive information system for medication delivery would result in a 28% reduction in ADEs, saving the hospital $1,449,000 (euro 1,200,199) per year.
The Institute of Medicine has called upon all healthcare organisations to develop comprehensive systems to ensure patient safety.(13) This will require changes in the culture and organisation of these institutions. Cultural changes are required to encourage the reporting of potential as well as actual errors to facilitate learning and changes in the system to prevent future errors from occurring.
Currently, only about 10% of medication errors are voluntarily reported. Organisational changes are also required.
There is considerable evidence that information systems that include physician order entry, decision support and alerting systems can significantly reduce errors and adverse events that result in injury to or the death of patients. However, many hospitals lack an electronic medical record that is needed to implement most decision support systems. Lack of integration of physician order entry systems, pharmacy systems and laboratory systems is another barrier to reducing medication errors.
Computerised systems are only part of the overall solution in preventing medication errors and ADEs. Pharmacists need to be more directly integrated into the medication delivery system at every stage. One hospital reduced the ADE rate in the intensive care unit (ICU) unit by two-thirds by having pharmacists participate in patient rounds with the ICU team.(14) This resulted in cost savings of $270,000 per year. Finally, medication administration and monitoring systems need to be improved. This should include barcoding of medications as well as improved labelling and warnings on medications with a high potential for harm to patients.
Most systems for the identification and prevention of ADEs have been developed for hospital inpatient settings. An important area for future research development is the development and implementation of IT in ambulatory settings. Because of the high volume of outpatient visits, IT has the potential to significantly improve the quality of healthcare and reduce costs.
A recent report by the Center for Information Technology Leadership(15) estimated that the universal adoption of ambulatory computerised provider order entry (ACOPE) systems that include decision could prevent over two million ADEs each year in the USA. This would result in a saving of approximately $44 billion (euro 36.5b) a year in unnecessary expenditures.
The President’s Information Technology Advisory Committee Draft Report calls for accelerated adoption of IT in the healthcare sector (W:www.nitrd.gov/pitac). The recommendations include the adoption of:
- Electronic health records to maximise the information available to healthcare providers at the point of care
- Computer-assisted decision support to increase compliance with evidence-based medicine.
- Electronic order entry in both outpatient and inpatient practice settings.
- Interoperable electronic information interchange.
It has been proposed that $100 million (euro 83m) be spent on promising health IT to facilitate the implementation of these recommendations.
I wish to acknowledge the assistance of Marilyn Anderson with the preparation of this paper.
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