Factors ranging from physician training to inadequate but expensive technology have contributed to a go-slow approach.
Editor's Note: This is the second of two articles about medical errors and the search for solutions by policy makers and health providers. Select for First Article.
Used with permission from Medscape Money & Medicine, © 2000 Medscape, Inc.
By Cathy Tokarski
Strategies to reduce the incidence of medical errors frequently point to the positive role that technology, such as bar-coded medications, hand-held wireless devices, and computer drug order-entry systems, can play.
Hospitals in the Department of Veterans Affairs (VA), long notorious for serious lapses in medical safety, are now adapting bar-coded medications and identification strips and wireless computer technology after a study at two VA hospitals in Kansas found these devices reduced medication error rates by 70 percent over a 5-year period. And several studies from the early 1990s showed dramatic reductions in anesthesiology errors after specially engineered safety devices were developed to prevent gas hoses from being installed at the wrong site.
While clearly not a quick-fix solution for medical mistakes, many error-reducing technologies face an unexpected barrier—slow adoption by physicians and health systems.
This hesitation comes at a time of heightened public and Federal interest in reducing medical mistakes, following last year's study by the Institute of Medicine (IOM) study that found such errors to be the country's eighth leading cause of death. The IOM identified a number of strategies, including implementing automated drug-ordering systems, to reduce the incidence of such errors over the next 5 years.
Health systems that have adopted error-reducing technologies have cut medication mistakes, reduced the rate of patient re-admissions due to drug interactions, and improved outcomes for patients, especially among those with chronic diseases. And the potential for faster adaptation is increasing, predicted John Eisenberg, M.D., who heads the Federal Agency for Healthcare Research and Quality, because technologies are becoming faster, more reliable, and portable. "Once [technology] migrates into the exam room, then we'll see more use of it because it will be easy.
Still, factors ranging from physician training and self-image to expensive but inadequate products have all contributed to a go-slow mentality, experts said.
Doctors are trained to make clinical decisions independently, without considering how their actions figure into a larger system of treatment, notes Tejal Gandhi, M.D., an associate physician at Brigham & Women's Hospital, Boston. "The concept of systems analysis doesn't come up," she said. Instead, doctors are mentored in an environment where "if you make a mistake, you feel like you are at fault," Dr. Gandhi said, which contributes to a culture of blame and secrecy.
In health care, "we pick people who are high achievers and have a high sense of social and personal responsibility," added Lucian Leape, M.D., a professor of health policy at the Harvard School of Public Health. Such individuals are loath to admit a mistake, let alone report it and open up an investigation.
To overcome that, health providers need to get "desensitized" to the concept of medical errors, he said. "People have to get to the point that when you say you made a mistake, we think, what is wrong with the system instead of what is wrong with that person, said Dr. Leape, the coauthor of the March 18 special issue of the British Medical Journal on medical errors.
Technology that can't anticipate common medical mistakes or communicate with existing systems also slows adoption rates. "Some of the technologies that are out there are not quite what they're cracked up to be," said Stephen Meisel, Pharm.D., assistant director for clinical pharmacy services at Fairview Southdale Hospital, Edina, MN.
A related frustration is new systems that can't communicate with those already in use, Meisel said. "There are some great computer order systems [for doctors] that don't talk to pharmacy systems, so the pharmacist has to re-enter everything into their system," he said.
A study by the Institute for Safe Medication Practices, a Pennsylvania-based nonprofit educational group, found that one-third of the computerized drug entry systems it surveyed allowed a health provider to override 10 incorrect orders, such as prescribing an inappropriate medicine for a particular condition.
The Institute and the American Hospital Association (AHA) recently formed a partnership to develop assessment tools hospitals can use to examine the quality of their error-reporting systems, see how they compare to others, and share best practices, said Carmela Coyle, AHA's senior vice president of public policy. "One of the key aspects is improving the level of communication about this," she said.
Finally, in an era of tight operating budgets, error-reducing technologies aren't often at the top of a Chief Executive Officer (CEO) or medical director's priority list. "Improvements cost money," said Dr. Gandhi, and "the cost savings may not be felt by the group paying the cost."
Kaiser Permanente, the Nation's largest nonprofit health maintenance organization (HMO), will invest approximately $2 billion over the next 3 years in computerized decision-support technology. The technology includes automated prescription drug and refill orders, laboratory results, and Internet-based patient consultations and medical guidelines for all of its medical groups, said president and CEO David Lawrence, M.D. He expects the system will reduce medication errors and provide more comprehensive patient care.
Not every health system can invest that sum in error-reducing or prevention technologies, however. And even the most sophisticated system can't replace the executive-level commitment, problem-solving approach, and teamwork across health professional lines needed to make significant improvements, experts said.
But, as in many endeavors, success in reducing medical errors breeds further success.
Building on the experience from its inpatient computerized physician order-entry system, Brigham & Women's Hospital is launching a similar system this summer in its outpatient clinics, Dr. Gandhi said. The inpatient system, launched in 1993, requires doctors to document all of their orders, including medications, laboratory, food, and activity levels. It is credited with saving the 726-bed hospital between $5 million and $10 million and reducing medication errors by 55 percent, according to a recent report from the National Coalition on Health Care and The Institute for Healthcare Improvement.
In the outpatient setting, doctors will be required to enter prescriptions on the computerized system, putting an end to hand-written orders. Initially, the system will check for patient allergies but other features, such as drug interaction warnings and prompts for needed laboratory tests or screenings, will be added, Dr. Gandhi said. Therefore, when a doctor writes a prescription for hypertension medication for an elderly patient, he will be automatically prompted if the patient is due for a mammography and flu shot.
While the huge cost-savings realized by Brigham's inpatient system aren't likely to be replicated on the outpatient side, Dr. Gandhi sees plenty of advantages. "The outpatient side is even more interesting when you think about the sheer number of patients" who are seen each day and "the fact that we don't have someone monitoring the patient 24 hour a day." And cost-savings and error reductions will be achieved through avoided hospitalizations due to adverse drug reactions or missed preventive tests or treatments, she said.
Brigham doctors' familiarity with the inpatient computer order-entry system—a comfort level that didn't occur overnight—bodes well for their acceptance of the new outpatient system, Dr. Gandhi said. "We're trying to make things that are a no-brainer easy, so that they can concentrate on the harder things."
At Fairview Southdale, a program to monitor cardiac patients using the anti-coagulant warfarin was launched after hospital data showed that an average of 1.7 patients per week, or 90 of the 4,000 using the drug, were admitted due to bleeding. About 70 percent of the admissions were thought to be due to an error in monitoring, dosing, or followup, according to the coalition report.
Two Fairview pharmacists were assigned to administer dosages to patients using protocols developed by the hospital and its affiliated Minnesota Heart Clinic. The pharmacists also conducted extensive patient outreach and education, making sure that patients got the followup visits they needed, Meisel said. After 6 months, warfarin complication rates fell from 12 per 100 cardiology patients to just 2. Blood tests revealed that patients with the correct dosage of warfarin in their system increased from 35 percent to 65 percent.
Meisel cites an open communication approach as an important factor, in addition to appropriate clinical protocols and extensive patient education. "One of the most important reasons for success is that we start off with a discussion of the problem, not with a discussion of the solution," he said.
Pharmacists sometimes err by identifying a problem and saying, "'We should have a renal dosing committee, or we should have a program that would solve everything,' " Meisel said. When approached that way, "the blinders go up, and [doctors] think pharmacy is taking over medical practice again."
By identifying the problem first, then agreeing that no one wants to see it repeated, the focus can then shift to "coming up with a mechanism to make sure it doesn't happen again. Pharmacists need to understand it won't always be a pharmacy solution, but that's OK as long as it works."
Used with permission from Medscape. Adapted from the original article posted May 30, 2000, at: http://ManagedCare.medscape.com/Medscape/MoneyMedicine/journal/2000/v01.n03/mm0530.toka/mm0530.toka.html
Current as of May 2000
Internet Citation:
Medical Error-prevention Strategies Face Barriers to Acceptance. May 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/medscap2.htm
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