Medication errors: Technology can reduce mistakes

Garth Bowen

By Garth Bowen and Leah Binder

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For a doctor, the difference between a prescription for “10 mg of Colchicine” and one for “1.0 mg of Colchicine” is the placement of one decimal point. For a patient, the difference between the two prescriptions is the difference between life and death.

A dose of 10 mg would likely cause Colchicine poisoning, which symptoms include burning in the mouth and throat, fever, vomiting, diarrhea, abdominal pain and kidney failure. Onset of multiple-system organ failure may occur within 24 to 72 hours.

Gruesome as the consequences may be, it's easy to see how this error could be made by a physician writing dozens of prescriptions a day. Indeed, medication errors are the most common errors in hospitals, with an estimated 1 million serious medication errors made each year, contributing to 7,000 deaths.

The best-known method for reducing those errors is a technology called computerized physician order entry (CPOE). The computer will alert physicians to the misplaced decimal on the Colchicine order, or other common errors.

The urgent case for more rapid CPOE adoption is compelling: the errors decline by as much as 85 PERCENT when hospitals implement CPOE.

The Leapfrog Group, which represents employers and other purchasers of care, is the only organization actively monitoring CPOE adoption. We find that only about 12 percent of hospitals have adopted CPOE in any inpatient unit.

But all the emphasis on hospital adoption of technology has obscured one important lesson that business leaders in other industries know well: Technology does not automatically work as promised. It must be implemented strategically, engaging and training all the stakeholders who use it. And it must be monitored to make certain it works as promised.

While this seems logical, it was not until Leapfrog launched a test of CPOE systems that a tool was available to hospitals to test and compare the performance of their CPOE systems.

This is not a minor issue. These new Leapfrog evaluation results reveal that when 214 hospitals used the simulation, as many as 52 percent of simulated orders that would result in adverse events were not flagged by their CPOE systems. About one-third of simulated orders that would have resulted in patient death were not flagged by the systems.

It is imperative that several things happen. First, stakeholders must come together and lay out the best practices for implementing CPOE for all to see. Competition is fine, but when it comes to patient safety, collaboration should trump competition every time. CPOE adoption is too complex for a proprietary approach. Adoption requires experience with management and change within the hospital system - and that is one of the toughest challenges in any hospital.

Second, purchasers should be monitoring whether the hospitals and their employees use CPOE, how well it performs and if it is monitored and adjusted on a continuous basis. We know CPOE is better than no CPOE, but we also know that unmonitored systems can defeat all of our efforts to make patient care as safe and efficient as it can possibly be. The solution is within reach, but we must resolve to get there the right way.

Hospitals in Iowa are encouraged to voluntarily report to the public on their CPOE improvement efforts as well as other quality and safety measures by completing Leapfrog's annual hospital survey. So far, only a few have chosen to do so.

More than 1,200 hospitals across the nation so report. This is important for all of us. Please encourage hospitals in your area to report to the Leapfrog Group.

Leah Binder is CEO of The Leapfrog Group, a national non-profit coalition of employers and purchasers to initiate breakthrough improvement in the safety, quality and affordability of health care. The 2010 Hospital Survey and other information are found at www.leapfroggroup.org.

Garth Bowen is a member of the executive council of the Iowa Health Buyers Alliance, an association of health care consumers and purchasers working for a patient-centered health system, improved quality, wellness, and increased transparency and public disclosure. Online at www.ihbaonline.org