To Err is Human

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

Yet many 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. 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. 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, experts 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 wristbands 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, the 2007 committee recommended that all prescribers and pharmacies begin using electronic prescriptions by 2010. Writing prescriptions electronically enables doctors and other health care providers to avoid many mistakes that are due to handwritten prescriptions. Electronic prescriptions can help the healthcare team check a patient's medical history and flag potential problems such as drug allergies, drug-drug interactions, and excessively high doses.

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.

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