On the morning of March 10, in the city of Seattle, Michael Blankenship was found dead in his bed. He was 15 years old. Why was he dead? He had recently been discharged from Seattle Children's Hospital after having dental work. The doctors there had given Michael an overdose of a Fentanyl pain patch—a pain patch which is used for patients with chronic pain, not for patients who had just finished a surgical procedure. On top of that, the "overdose" turned out to be the maximum dosage of that particular patch. It was the conjunction of these two events that led to the death of Michael Blankenship. The death of the 15 year-old, though unfortunate and saddening, is not a rare occurrence in the medical world. Overdose is a common problem in hospitals and pharmacy chains; unfortunately, dosage problems are among one of the more serious cases of what is known as a medication error.
Medication errors, as defined by Carey M. Noland and Nathaniel M. Rickles in the journal Health Communication, are "preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer" (351). Such errors include wrong dosage of a particular medication as seen with Blankenship, misinterpreting a given order for the preparation of a medicine, and distributing the medication to the wrong person. All of these contribute to the vast number of medication errors—in fact, "The annual cost associated with medication errors has been estimated at $887 million" (351). The journal goes on to state that this figure is most likely an underestimation, that there are other costs associated with medication errors that are not included in this annual cost. In addition, this figure is expected to rise in the coming years with an increase in population and more spending on medicine.
So what causes these medication errors? With statistics speculating that the amount associated with medication errors is bound to increase, there should be an answer that can reduce that figure, or at least stop it from increasing any further. Is it just a simple mistake, or is there a missing link that allows for these errors to occur? Robert E. Ferner and Jeffrey K. Aronson wrote an article in Drug Safety and proposed a classification for medication errors. This classification contains three sections: mistakes, slips, and technical errors (1016). Under the category of mistakes falls the errors associated with knowledge. If a doctor prescribes a drug that ignores any fact about the patient or any ingredient within a drug that can cause potential harm to the patient, then that doctor is making a mistake. A slip is generalized for any error resulting from the action of the doctor or pharmacist. Slips include writing down the wrong name of the medicine, handing the drug to the wrong person, and picking the wrong medicine from the storage. The last proposed type of medication errors are technical errors, or errors made because of a lack of skill. For example, in one study, "two or three infusions of acetylcysteine contained amounts of drug that differed by >10% from the appropriate dose" (1016). Acetylcysteine, when given in an overdose, according to Mant, Tempowski, Volans, and Talbot in the British Medical Journal, is capable of killing people, as shown in the two deaths from the survey (218). However, the journal also states that it is incorrect to directly relate the two events back to the overdose. According to the journal, "a direct effect cannot currently be confirmed" (219).
Aside from the classified possible causes for medication errors, there are other ways in which medication errors can occur. Giampaolo P. Velo and Pietro Minuz from the British Journal of Clinical Pharmacology put forth another factor in medication errors. Although they do agree with the classification put forth by Ferner and Aronson, they also believe in one other factor: communication (625).
Communication is vital in the medicinal world. Doctors cannot possibly do both their job and also play the role of a pharmacist—it is physically demanding and impossible to carry out.
Therefore, there needs to be a solid line of communication between the doctor and the pharmacist. The doctor needs to prescribe, and the pharmacist needs to be able to read the prescription and deliver the correct medicine to the patient. In addition, the patient has to communicate well to the doctor where the sickness is, exactly what condition they are in, and they must do so to the pharmacist as well. Yet in instances of medication errors, it is clear that these strands of communication are lost. At times the doctor writes an illegible prescription, the patient does not correctly state their physical condition, and the pharmacist does their own diagnosis and hands the wrong drug to the patient.
Professors Carey M. Noland and Nathaniel M. Rickles at Northeastern University have looked into these errors through the perspectives of junior doctors in order to remedy them. Noland and Rickles published in Health Communication their experiment with junior doctors on medication errors and their thoughts on what needs to be done. In interviewing junior doctors, Noland and Rickles found five dominant themes in the students' responses. These themes are: pressure to be perfect, feeling comfortable talking about mistakes, assuming and communicating responsibilities for mistakes, learning how processes can contribute to errors and their prevention, and inadequate and inconsistent training on how to handle medication errors (354). Out of these five themes, two are related to communication between pharmacists, one is related to the system of dispensing drugs, and one is related to the teaching curriculum for upcoming pharmacists.
The fact that two of these five points relate to communication speaks lots about the current system that is employed. For example, in theme two—feeling comfortable talking about mistakes—most students answered that they would talk to the pharmacist who made an error, but they seemed hesitant at the same time (355). The others who stated that they would probably would not have made that answer because of interpersonal relations with that coworker. For example, if the person did not know the coworker that well, the person stated that he or she would most likely not want to be confrontational about it. If the pharmacist who dispensed the drug never realizes this mistake and is never told about it, this error could happen again next time. Even in the cases where that particular pharmacist is notified of the error, no report was filed for that error, another lack of communication.
Although there seem to be many fundamental mistakes that result in medication errors, there are also proposed solutions. One very logical solution is better communication. Better communication will result in more mistakes being caught before the drug is sent out, leading to fewer patients being potentially harmed from a wrong dosage or other mistakes. The British Journal of Clinical Pharmacology proposes a diagram aimed at reducing errors (626). In this diagram, the junior and senior doctors are always in communication with one another, reviewing the prescription. This constant communication is exactly what is needed to spot mistakes and to take care of them before it is out of the pharmacist's hands. For instance, Dr. David Fisher, the Medical Director of Seattle Children's Hospital, put the blame on the system by stating that the fault cannot be placed on any one individual; rather, the system of checking and re-checking the medicine failed at multiple points (KIROTV). Had there been a more systematic way of checking, the overdose may have been caught and it may not have been administered to the child.
Instead of "theorycrafting" solutions such as a diagram proposing a better communication system, an actual study was done in which doctors used new and detailed prescription papers to prescribe drugs (Kennedy, Littenberg, Callas, and Carney 152). This study was done to see how much doctors' handwritings contributed to medication errors. In this new prescription paper, doctors had to write in "tall-man lettering", had to write out abbreviations, and had to circle instructions on taking the medication, the dosage information, strength, etc. In general, this reduced common mistakes made from illegible handwriting. Surprisingly, the results showed that the new paper did not improve prescriptions. Rather, it increased prescription errors due to the complicated format of the paper (157). Only the handwriting legibility was improved.
Going back to the work of Ferner and Aronson and the classification system, proposed solutions overlap on each of the three types of errors. Knowledge-based mistakes can be taken care of through more diligent studying and focusing. In addition, computerized systems can be implemented to make decisions for the pharmacist. A system cannot be susceptible to knowledge-based mistakes, making it a viable tool to prevent this first category of errors. Communication between many pharmacists is a way to prevent slips. If there are multiple pharmacists checking each step along the way, these slips have a lower chance of occurring. In addition, checklists can be implemented, along with computerized reminders. Lastly, technical errors can also be taken care of through better skill training (Ferner, and Aronson 1018).
In the end, medication errors are part of the whole system of dispensing drugs. There will always be a mistake, a system that will never be foolproof. There will continue to be incidents and stories in the news similar to Michael Blankenship's. Although the ideal solution would be to completely eradicate medication errors through possibly the use of more computerized systems—systems that cannot be subject to human error—realistically, it cannot happen. Therefore, the only plausible solution is to reduce the number of medication errors. Hopefully, through a better communications system and a more effective education system, pharmacists will be able to interact with one another more frequently, and will be less susceptible to mistakes, slips, and technical errors.
Works Cited
Ferner, Robert E., and Jeffrey K. Aronson. "Clarification of Terminology in Medication Errors." Drug Safety. 29.11 (2006): 1011-22. Print.
Kennedy, Amanda G., Benjamin Littenberg, Peter W. Callas, and Jan K. Carney. "Evaluation of a Modified Prescription Form to Address Prescribing Errors." Am J Health-Syst Pharm. 68. (2011): 151-57. Print.
Mant, T G K, J H Tempowski, G N Volans , and J C C Talbot. "Adverse Reactions to Acetylcysteine and Effects of Overdose." British Medical Journal. 289. (1984): 217-19. Print.
Noland, Carey M., and Nathaniel M. Rickles. "Reflection and Analysis of How Pharmacy Students Learn to Communicate About Medication Errors." Health Communications. 24. (2009): 351-60. Print.
Velo, Giampaolo P., and Pietro Minuz. "Medication Errors: Prescribing Faults and Prescription Errors." British Journal of Clinical Pharmacology. 67.6 (2009): 624-28. Print.
KIROTV. "Seattle Children's Admits Medical Mistake Killed Boy." (2009) http://www.kirotv.com/health/21149359/detail.html
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