HIMSS Analytics survey: Medication safety falls perilously short of patient expectations

The key to moving toward “zero” errors rests in constructing a system that is purposefully designed to stop the inevitable human errors before they can do any harm.
09:50 AM
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Patients trust that healthcare organizations will provide safe care. Unfortunately, that trust is often broken, according to the results of a survey of 1,131 patients and family members recently conducted by HIMSS Analytics and sponsored by BD.

More than 96 percent of survey respondents have confidence in their care team to administer medications according to the five rights (right patient, drug, dose, route and time), yet 38 percent know someone who has experienced a medication error. And, one out of five of these patients suffered from “severe repercussions.”

Chris Jerry has firsthand knowledge of the disconnect between expectations and the unfortunate realities of patient care. Jerry’s 2-year-old daughter Emily received extraordinary medical care in 2006 and thus was on her way toward beating cancer.  When his daughter was on her final treatment, a hospital pharmacy technician prepared the wrong intravenous (IV) solution to Emily, however, the consequences proved fatal.

“If the pharmacy just had simple barcode verification in their workflow, and that young pharmacy technician, who didn’t know any better, took that first vial of hypertonic saline and scanned it, alerts would have gone off. And, if that had happened, I am convinced that my beautiful daughter would still be with us today,” said Jerry, who now serves as the founder, president and CEO of the Emily Jerry Foundation.

Putting such safeguards in place, however, is not an easy proposition. “It’s important to understand that the medication process is complex. So, you’ve got a highly complex system with a lot of moving parts, and in complicated systems like that, the likelihood of error can be quite high,” said Tejal K. Gandhi, MD, chief clinical and safety officer for the Institute for Healthcare Improvement. “If you look at the full medication process from the time a physician orders a medication and the order goes to pharmacy and the pharmacist dispenses it, and then it goes to the bedside where the nurse administers it, there is the potential for errors in each of those steps.”

The key to moving toward “zero” errors rests in constructing a system that is purposefully designed to stop the inevitable human errors before they can do any harm. “In the past, when medication error tragedies occurred, everybody would point the finger at the individual healthcare practitioner who is responsible, but instead we need to focus on where did the systems, processes and protocols break down?” Jerry said. “We need to hyper-analyze each event and go back and modify the core systems, processes and protocols so that we can design out that probability of human error from creeping into the equation.”

Gandhi agrees. “The key is to do a really robust cause analysis to understand why the error happened and how to redesign the systems to prevent it,” she said.

The good news is that the healthcare industry has made significant progress in developing and implementing technologies – from computerized physician order entry to automated inventory management systems in pharmacies to dispensing systems that make medications available for patients – that can help eliminate the preventable human errors. As these technologies become more integrated, the information exchange between the solutions becomes more robust, driving healthcare organizations to further protect patients from adverse events.

Comprehensive, integrated IV workflow technology, for example, could help eliminate errors such as the one that led to Emily’s fatality. This integrated system could include IV prep technology, barcode verification and gravimetric technology (which provides independent validation that the IV bag’s final weight is within predefined accuracy limits for the specific compound) that works together to “ensure the proper volume or the right dose of medication goes into the IV bags,” Jerry pointed out.

Certainly, many healthcare organizations have implemented some of these technologies, and increasingly these technologies are integrated together to make a more seamless system. In addition, the industry has made significant strides toward improved patient safety since that day in 2006 when a medication error took Emily’s life. However, healthcare leaders still need to remain dedicated to safety and continue to innovate for the ultimate purpose of improving patient outcomes.

“We're headed in the right direction and are making a lot of progress on medication safety based on those technologies getting implemented. But every new technology can create new problems, so we constantly have to concentrate on what can be done to mitigate those,” Gandhi said. “Healthcare organizations can never feel like they’re ‘done’ because there’s always going to be things that you can do to improve and further prevent medication errors.”