PROGRESS IN PREVENTING ERRORS

Reports from the Institute of Medicine don't usually create a media sensation. But "To Err Is Human," the institute's 1999 study of medical errors, did just that by estimating that as many as 98,000 Americans may die from medical mistakes each year--more than from AIDS, breast cancer or car accidents. The institute concluded that medical practice and technology had become very complicated, and that it was dangerous to rely on the memory of health professionals. Doctors and nurses could not be expected to remember every medication a patient is taking, every drug allergy and all possible adverse interactions. Instead, the institute argued, health-care organizations should aggressively invest in systems that avert mistakes.

What has been done since then? Both a lot and not enough. Much of the focus has been on preventing medication mistakes, the single biggest cause of preventable medical injuries and death. In hospitals, more than half of medication errors occur when a drug is being ordered. The doctor forgets that the patient is allergic to the drug, the dose is wrong because the patient's kidney function is impaired, or the pharmacist can't read the doctor's handwriting. Millions have been invested in drug-ordering systems. Such systems have cut medication-ordering errors by as much as 80 percent. Mistakes that occur as drugs are being administered, the other high-risk step, can be prevented by bar-code systems. The nurse scans the bar code on the medication and the patient's wristband, and the match is double-checked against data in the hospital-pharmacy computer. To work well, computerized ordering systems must be fast, clear and easy to read. When they aren't, nurses and doctors will quickly figure out shortcuts to get their work done, bypassing safety checks.

Pharmacists can fill in knowledge gaps by working with doctors in the hospital and by counseling patients at the local pharmacy. But if they're to counsel patients, they need to be compensated for their time. Instead, community pharmacists have been under enormous pressure to dispense more and more prescriptions for less reimbursement.

What can you do to prevent medication errors? Knowing what medications you are taking, their doses and what they look like will help you intercept errors. Reliable drug information can be found at several Web sites, including medlineplus.gov. In our view, medical practice is safer today than it was five years ago, but there still is much more to be done. Not only are more systems necessary, but health professionals need to change how they think of themselves--more as fallible members of a team, and less as infallible rugged individualists. To err is human. Not to err requires supportive systems, and a whole new way of thinking.

LEAPE IS ADJUNCT PROFESSOR OF HEALTH POLICY AT HARVARD SCHOOL OF PUBLIC HEALTH. WEHRWEIN IS EDITOR OF THE HARVARD HEALTH LETTER. FOR CONSUMER INFORMATION, GO TO HEALTH.HARVARD.EDU.

© 2005