QUALITY: Hospitals Combat High-Risk Medication Errors

Joanne Kenen - 

Remember that scary Institute of Medicine report a few years back about the 98,000 fatal medical errors in hospitals each year? And the conclusion that it wasn't the fault of a few "bad apple" or incompetent doctors and nurses, but layers of unnecessary hazards built into the system? The problems range from confusing packaging to the "hurry up and rush" culture of hospitals. Today's Wall Street Journal has an interesting article on how hospitals are rethinking how they use the riskiest drugs--the eight medications which studies have shown account for nearly one-third of the drug errors that harm patients.

The Journal reports that hospitals are "working with drug makers to redesign confusing packages and eliminating multiple concentrations of the same drug from supply cabinets. They are also investing in bar coding and systems that let staffers check the accuracy of medication orders at patients' bedsides and see other information, such as allergies, that could cause adverse reactions. In perhaps the most challenging step, hospitals are tackling the "grab and go" culture in busy hospitals that evidence increasingly shows causes dangerous errors."

One simple tool is making two people check prescriptions. I saw this in practice last year when I was doing some reporting at the pain clinic at Virginia Commonwealth University's medical center. They use heavy-duty narcotics for patients with metastatic cancer or severe back pain, and I watched as the nurses whipped out their calculators and double-checked each other's decimal points....