To Err is Human                    Return to the Beginning

When medical mistakes happen, they're typically blamed on an individual mistake, according Dr. Lawrence. In fact, one of the long-standing principles of medicine is a deep-seated belief that every professional should be perfect.

Yet Dr. Lawrence and many other experts believe that the rampant errors do not reflect widespread incompetence. The data on medical errors shows that as human beings, health-care providers are inherently fallible, according to Brent James, MD, executive director of Intermountain Health Care, Institute for Health Care Delivery Research, in Salt Lake City and a co-author of the IoM report. Regardless of the training, even the very best professionals make mistakes. People with 20 years of experience have made fatal medication errors, according to Diane Cousins, RPh, vice president of the Practitioner and Product Experience Division the U.S. Pharmacopeia - a Rockville, Maryland-based group that sets standards for drugs and dosages.

Part of the problem is that to get from diagnosis to safe delivery of a drug to a patient in the hospital can involve 40 to 60 separate steps, and each one of them is an opportunity for error. (See Table 1.)

[Table 1]
Table 1. Medication Use Processes

Prescribing

assessing the need for and selecting the correct drug

individualizing the therapeutic response

designating the desired therapeutic response

Dispensing

reviewing the order

processing the order

compounding and preparing the drug

dispensing the drug in a timely manner

Administering

administering the right medication to the right patient

administering medication when indicated

informing the patient about the medication

including the patient in administration

Monitoring

monitoring and documenting patient's response

identifying and reporting adverse drug events

reevaluating drug selection, regimen, frequency and duration

Systems and Management Control

collaborating and communicating amongst caregivers

reviewing and managing patient's complete therapeutic drug regimen

Source: Nadzam DM. Development of medication-use indicators by the Joint Commission on Accreditation of Healthcare Organizations. AJHP, 1991; 48: 1925-1930, as reproduced in Kohn LT, Corrigan JM, Donaldson MS (eds) and Committee on Quality of Health Care in America, Institute of Medicine: To Err is Human: Building a Safer Health System, Washington, D.C., National Academy Press, 2000, p. 38.

Instead of pointing fingers, Dr. Lawrence and the other experts who wrote the IoM report call for identifying the steps where mistakes most often occur and implementing safety systems that help prevent them. For example, putting supermarket-style bar coding on patient wrist bands and drug dispensers can reduce mistakes resulting from patient mix-ups. Using a hand-held device, a nurse can swipe both codes to be sure that the right drug gets to the patient for which it is intended.

Technology can also be used to address one of the most common causes of medication errors: drug prescriptions scribbled in illegible handwriting. To remedy the problem, experts recommend that hospitals install computer systems into which physicians must enter and transmit drug prescriptions. The most sophisticated systems not only solve the handwriting problem but also flag other common sources of trouble such as improper drug doses, potentially harmful drug-drug interactions, or a high risk of an allergic reaction.

If a computerized drug-order system had been in place when Betsy Lehman was admitted to Dana-Farber, she probably wouldn't have been given the fatal overdose. She was supposed to receive 1,000 milligrams of a chemotherapy drug per day, for four days. Instead, she was given 4,000 milligrams each day. The total dose had been mistakenly written on an order form intended to indicate the daily dose.