The Shocking Truth About Medication Errors

Let’s say a physician writes a prescription for Colchicine and accidentally orders “10.0 mg,” when he should have ordered “1.0 mg.” That’s a tiny decimal error, a mistake even the best doctor could make. But it can be catastrophic for the patient. The higher dose could cause Colchicine poisoning, similar to arsenic poisoning: burning in the mouth and throat, excruciating abdominal pain. Internal organs would melt away and death would likely occur within 24 to 72 hours.

The ease with which even the best doctors can make gruesome errors is why hospitals set up elaborate systems to check and double check orders before drugs are given to patients. Some hospitals are better at this checking than others. Medication errors happen all the time, an estimated one million each year, contributing to 7,000 deaths. On average there is one medication error every day for every inpatient. Let’s take a closer look at what’s contributing to these preventable errors.

Hospitals Are In The Technological Dark Ages

According to recent research, the best known way for hospitals to protect patients from errors is by adopting technology called computerized physician order entry (CPOE). The physician (or other authorized prescriber) enters orders for a patient on a computer that contains patient information such as key lab values, clinical condition, allergies, etc. The computer checks the safety and appropriateness of the order and sends it electronically to the pharmacy. In the Colchicine example, a good CPOE system would alert the physician to the misplaced decimal in the order, and the best systems would prevent the order from being written in the first place. In my mind, one of the greatest advances of CPOE is that it eliminates the need for pharmacists to decipher physician handwriting. I’ve often wondered how they do that.

The research suggests errors decline by as much as 85 percent when hospitals implement CPOE, yet the pace of adoption in the hospital industry is agonizingly slow. To jump start progress, the federal government used economic stimulus funds starting back in 2009 to incentivize hospital investment in CPOE and electronic medical records (EMRs). That improved the pace of change, but still, most hospitals are in the Dark Ages when compared to other industries like airlines or retail.

My nonprofit, Leapfrog, finds that only about a third of the hospitals that voluntarily report to our survey meet our standard for full implementation of CPOE. Even for that minority of hospitals that adopt CPOE, the system doesn’t always work as advertised. Like all technology, CPOE must be continually tested and modified. That’s not always happening.

We know this because Leapfrog offers a CPOE test developed by experts at the nonprofit patient safety innovator TMIT, which allows hospitals (for free) to test whether their systems actually prevent common medication errors. Unfortunately, we find among hospitals taking the test that about 50 percent of the time the CPOE systems fail to properly alert to problem orders, even though some of those orders, if administered to a real patient, could cause death. Believe it or not, the TMIT evaluation is the only such test of decision support systems available to hospitals today — at least that we know of. The good news is that when hospitals repeat the test after a few months, they almost always improve, proving that the process of testing and monitoring is the key to the safety of CPOE systems.

Three Ways To Fix The Problem

It is imperative that several things happen to protect consumers from medication errors. First, stakeholders must come together, lay out the best practices for implementing CPOE and make it available to all of the nation’s hospitals immediately. Today, many hospitals rely on their vendors for instruction and full implementation.  But vendors’ interests do not always make patient safety a top priority — that’s the job of the hospital. Hospitals need more tools and collaboration to successfully adopt this technology.

Second, taxpayer money invested in health care should hold hospitals accountable for preserving the safety of patients. This sounds so obvious it hardly needs to be stated, except, well, it needs to be stated – because it’s not the case today. Despite our repeated pleadings and those of our purchaser members, the administration’s current criteria for paying hospitals to install CPOE doesn’t require the hospitals to test and monitor the safety of their CPOE systems. This is a mind-boggling oversight, suggesting it is more important to your government that hospitals have whizz bang technology than prove the technology actually works for the patient.

The giant federal agency that funds Medicare, Centers for Medicare & Medicaid Services (CMS), will tie some of its payments to hospitals to their safety record — which is a good thing, required by ObamaCare. But, as purchaser and consumer advocates complained in a letter to CMS, there is no plan to include medication errors in the criteria for determining how safe hospitals are. This makes little sense, since medication errors are far and away the most common errors hospitals make.

Finally, employers and other purchasers should favor hospitals that have a monitored CPOE system. That means they should tilt toward these hospitals in benefits design and contracting. In addition to the harm done to your employees when CPOE systems are not in place or are deployed badly, errors are also costly to purchasers. And it’s purchasers — not hospitals — that pay most of the price tag for those errors. Purchasers can actually estimate how much they are paying for the privilege of harming employees using the free tool available here.

The Real Reason Hospitals Don’t Invest In The Right Technology

The fact that hospitals can usually pass the cost of errors to purchasers is precisely the reason adoption of CPOE stalls. Hospitals are much speedier and technologically savvy when their profits are threatened.

Think that’s a wee bit too cynical? A report in last week’s issue of the foremost hospital industry trade publication, Modern Healthcare, detailed a range of new tech wizardry hospitals are using to collect payment from their patients. My favorite was a hospital system highlighted for its ePay portal, “recently enhanced… adding future payment scheduling, mobile alerts and payments and enhanced messaging services. “Hospitals in that system haven’t yet found the time to adopt CPOE, despite considerable pressure from purchasers to do so. Apparently, it’s hard to protect your patients from errors when there are so many bills to collect.

In fairness, hospitals respond to health care financing incentives from the government, as well as the private sector, and those incentives rarely reward hospitals for doing the right thing. To their immense credit, many hospitals competently deploy CPOE and electronic health records (EHRs) whatever the financial benefit. Next it is up to us — as citizens, patients and payers — to focus our attention and our market power on those hospitals, the ones that put their patients’ health and well-being first.

Leah Binder is the CEO of The Leapfrog Group, a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. She blogs regularly at Forbes, where this piece originally appeared.

8 replies »

  1. CPOE is garbage in garbage out. As long as no one pays for the time spent doing this, the results are going to continue to be poor. If you are trying to save lives with technology and apps then you are wasting your time. Medicine is primarily a social discipline and requires human contact and reasonings.

  2. Don’t forget the role of a well trained nurse to intercept wrong meds. It’s the job of the nurse to administer the drugs and they need to be fully aware of what’s going on, not just be the doctor’s hand maidens.

    Sandra’s right, we’ve become too comfortable and dependent of “technology” to eliminate our ability to THINK.

  3. I think that Leah’s post points out one of the most intractable problems in health care: the hospital industry (which is largely profitable, even though it is mostly not-for-profit) is arrogant and intransigent in its unwillingness to reform itself. I have never met a hospital administrator for whom the phrases “optimize payer mix” and “maximize reimbursement” were not repeated like some bizarre mantra, especially behind closed doors. Similarly, I’ve never heard one muttering “keep patients safe.”

    Employers might be the route to change, perhaps with the design of narrow networks that favor hospitals with the most sophisticated patient safety systems, but even that might have just limited impact. I think it is time to teach patients and their families start to use social media as a disciplinary tool. How long do you think it will take for a hospital to fix its processes when Twitter and Facebook explode with parental outrage after a child is inappropriately medicated? And then reporters descend. And then the bloggers. And, all of sudden, the issue just won’t go away.

    Sometimes it takes lots of bloody noses to fix a problem, and for some reason, hospitals and health systems believe themselves above the fray. Why? Because we let them off the hook.

  4. I’m guessing this is the fallacy of the loudly competing budgetary priorities in action. Seems logical that most people are going to deal with getting their EMR problems solved first …

  5. I’m always fascinated by the idea that everyone in the healthcare field is supposed to be motivated purely by altruism and the serving of humanity. It’s a great idea, really. But which field is entirely driven like that – politics, finance, technology, manufacturing, aerospace, retail?? The answer is none of them. Not even the church ignores finances.

    The bottom line matters to everyone. But that doesn’t mean there isn’t a desire to also serve the greater good. The goal is to ideally align incentives so that doing the right thing doesn’t cause massive financial harm to one’s organization. There is no question that CPOE and a series of checks like those found in the aviation industry can make a difference (the computer, alerts, pharm D’s). But to dismiss the fundamental issue of profit and sustainability is to ignore the basics of motivation and human behavior.