- The Washington Times - Tuesday, December 26, 2000

A few hospitals are defying tradition by openly reporting staff errors in medicating patients, providing what specialists call "a first glimpse into the types and causes of medication errors."

Fifty-six of the nation's 6,000 hospitals have recorded details of medication mistakes in a first-of-its-kind database called MedMARx. The facilities that reported foul-ups are the first of an increasing number of hospitals joining in a new attempt to curb the miscues that occur in prescribing and administering medications.

In just 12 months the first full year of MedMARx operations the hospitals reported 6,224 drug-therapy errors that injured 186 patients and killed one.

U.S. Pharmacopeia, a private, nonprofit health safety organization, established and oversees MedMARx, which is described as an "Internet-accessible database for hospitals to report and track medication errors anonymously."

Last week in a 33-page report and in a subsequent telephone news conference, Pharmacopeia officials indicated that the injury and death rates from medication-related mistakes is comparatively low yet significant.

The number of medical prescription foul-ups reveals "merely the tip of the iceberg," said Dr. Roger Williams, Pharmacopeia's chief executive.

Dr. Williams noted that 6,037 of the 6,224 error victims were unharmed. Yet, he explained, "Just 1 percent of U.S. hospitals provided information … and most drug administrations occur outside hospitals."

Furthermore, Dr. Williams estimates that perhaps 1 in 20 errors that occur actually are recorded. Hence, he believes the National Academy of Sciences' Institute of Medicine was probably correct in reporting last December that medication errors annually cause up to 7,000 deaths.

The Pharmacopeia analysis of the reported errors revealed that most of them consisted of failing to provide ordered medications, giving the wrong amount of a prescribed drug or administering the wrong medicine.

Drugs were also given at the wrong time or the wrong way for example, by a pill instead of by injection, or by an injection given in the wrong part of the body.

The drugs most commonly implicated in the reported medication errors were heparin, a blood-thinning drug prescribed for stroke victims; warfarin, a blood clot preventative; and insulin, which is essential for lowering blood sugar levels in many diabetics.

The blunders committed using these and other drugs mostly occurs when the drugs are being administered and documented.

An error in administering would take place, for instance, when too much or too little of a drug is given. A "documenting error" would be recorded when the order prescribing the medication was imprinted with the wrong name of the patient or of the drug.

Error analysis shows such mistakes typically happen when nurses, technicians or pharmacists are distracted or are laboring under "workload increases, many of which may be a result of today's environment of cost containment," the report states.

But there are other common causes too. Among them: inexperience, failure to communicate instructions, failure to provide patient information, use of temporary help from agencies, emergencies, inattention caused during changes in work shifts, lack of 24-hour pharmacy service and even "poor lighting."

Identifying the causes of error is perhaps the most important function of the error-reporting effort. That's because studying the causes of past mistakes is seen as essential to creating systems for avoiding future bumbling.

Beyond that, however, Pharmacopeia officials say that more than 200 hospitals recently have joined the 56 pioneers in reporting errors to MedMARx.

This is taken as a sign of an important "cultural shift" among hospital administrators. Previously, they tended to conceal mistakes and often failed even to tell the offenders that they had botched a treatment.

Pharmacopeia officials believe the report signals the beginning of an effort to provide greater accountability in curbing medication errors.

"While this report reflects preliminary data from MedMARx's first operational year, we see this as a first step in establishing better practices throughout the health care system," Dr. Williams said.

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