PREVENTING MEDICAL ERRORS PART 1
Gloria Coronel-Couto, MD, Assistant Professor of Medicine, University of Miami Miller School Medicine
| Introduction: American College of Physicians (ACP) received grant from Agency for Healthcare Research
and Quality to address problem of medical errors; speaker 1 of 50 physicians selected by ACP
from faculties of medical schools around country to attend conference in Philadelphia; in “training the
trainers” sessions, participants learned how to train other physicians in strategies to prevent medical errors
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| Objectives: to become aware of importance of patient safety; to recognize areas of practice that need restructuring
to prevent errors; to discuss current national patient safety initiative
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| To Err is Human: title of 1999 report from Institute of Medicine (IOM); 44,000 to 98,000 preventable
deaths each year (in hospital setting; many more in outpatient setting); medical errors leading cause of
death, eg, more than breast cancer, accidents, pneumonia, influenza, and diabetes
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| Causes of problem: excessive fatigue on job; overloaded work schedules; chronic shortage of staff; health
system supported by students, interns, and residents (study found as many mistakes made by attending
physicians with 30 yr of experience)
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| Problem can be fixed: requires time and effort; need to adopt culture of safety; need to realize errors come
not from bad people but from bad systems
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| Big gap: between what we know is good quality care and how we normally practice; we deliver only ≈55%
of recommended care, eg, atrial fibrillation (many patients not receiving warfarin [Coumadin]), urinary
tract infections (antibiotic therapy for 7 days when 3 days adequate); example from board review course—
90% of participants correctly answered question about inhaled steroid therapy for asthma, meaning that 10
of 100 patients would not receive appropriate therapy
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| Patient safety includes providing proper therapy: affects overall outcome and patient mortality; errors
of omission—not knowing when to provide immunization and recommended screening (eg, for cervical
or colon cancer, hypertension); many deaths result from gaps in reducing risk factors; obesity increases
risk of Alzheimer’s disease, cardiac and liver disease, and osteoarthritis; obesity and smoking account
for 400,000 deaths annualy; National Committee for Quality Assurance estimated in 2003 that 57,000
deaths result from lack of recommended health care (eg, no β-blocker after myocardial infarction [MI])
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| Possible answers: use of electronic decision support system, eg, personal digital assistant (PDA) or computer;
provides ability to check drug-drug interactions and dosing while prescribing; access to current
evidence-based medicine during physician-patient interaction
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 | Resources:
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| Medical Calculator (MedCalc): provides, eg, glomerular filtration rate, body mass index, steroid conversion
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| National Cholesterol Education Program: offers 10-yr cardiovascular risk calculator
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| Stanford Guide to Antimicrobial Therapy: provides annual changes in recommendations
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| UpToDate: available at uptodate.com; provides current information on diseases and therapies
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| Reasons to use electronic support: memory unreliable; “it’s not about knowing everything; it’s about
knowing where to look for information”
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| Advantages: improves patient care; improves patient safety; increases efficiency; improves accuracy;
improves communication
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| Disadvantages: cost; time; human error still exists
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| Errors in prescribing medication: complex system involved; writing correct drug and dosage; transmitting
to pharmacy; pharmacist entering prescription into computer; selecting right drug from supply
shelf and placing into bottle; giving medication to patient (obtaining signature for counseling); physician
monitoring for side effects
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| Source of errors: 39% from writing incorrect prescription (wrong drug or dosage); transcription by staff
(illegible handwriting); dispensing by pharmacy; administration by nurse (38% of errors); 15% of physicians
have illegible handwritings
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| Malpractice: medication errors involved in many malpractice suits
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| Examples of illegible prescriptions: could be read as Prozac or BuSpar; “6U” mistaken for 60 units; drug
could be read as Coumadin (warfarin) or Avandia (rosiglitazone)
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| How to avoid medication errors:
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| Print clearly
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| Avoid verbal orders
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| Write drug strength
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| Write dosage form
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| Write amount
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| Write number of refills
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| Include directions for use (not “use as directed”)
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| Do not use abbreviations: use daily, not qd; unit, not U; mcg, not µg; subcutaneous, not “sc” or “sq”; discontinue
or discharge, not “d/c”
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| Be careful with decimals: never leave decimal point “naked” (0.5, not .5); never use terminal zero (1 mg,
not 1.0 mg); avoid decimals when possible (125 mcg, not 0.125 mg)
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| Be careful with look-alike or sound-alike drug names: Tegretol XR and Toprol XL; Accupril and Accutane;
Flomax and Fosamax; Lamisil and Lomotil; Zantac and Zyrtec; report resulting medication errors
to United States Pharmacopeia (may require drug company to make name change or change label)
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| Avoid verbal orders: if necessary, speak slowly; state numbers (one-five, not fifteen); spell out difficult
drug names; have other person repeat it to you (most important)
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| Advantages of electronic prescribing: database with drug history and information on drug and patient,
eg, allergies; avoids illegible prescriptions; avoids incomplete information (prescription cannot be
printed until all information entered); avoids ambiguous orders; however, still room for human error
(eg, entering wrong patient name)
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| Legible Prescription Law: became effective in Florida July 1, 2003; no penalty for noncompliance; includes
above recommendations on legibility and prescribing information
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| Bar coding: patient, physician, and medication assigned bar code, like items in store; study in Veterans
Affairs hospital using bar coding documented decrease of 24% in medication errors; expensive
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| Where to report medical errors: reports analyzed for need to recommend change
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| United States Pharmacopeia
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| Institute for Safe Medication Practices
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| Tell them about: their medications; condition treated; name of drug and how to take it
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| Put instructions in writing
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| Involve patients in system: eg, warn them that errors happen frequently
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| How people feel about health care: national survey in 2004 found >55% currently dissatisfied (only 44%
when surveyed 4 yr before); 40% believe quality of health care has “gotten worse”; 50% concerned
about their medical care
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| Communication: establishing good relationship with patients helps prevent malpractice lawsuits; how we
communicate as important as what we say (eg, establish eye contact); communication makes evidence-
based medicine real to patients; communication improves outcomes for patients and physicians; physicians
overestimate by 900% time spent with patients
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| Levels of communication in medicine
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| Physician-patient
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| Physician-specialist: referrals; follow through to ensure patient sees referral physician and has appropriate
test
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| Physician-staff: “there is no dumb question”; tell staff to ask physician if instructions or handwriting not
understood
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| Physician-diagnostic center: eg, physician should make sure radiologist knows what he or she is looking
for
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| Specialist-physician: failure to convey results of referral
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| Patient-physician: tendency to minimize significance of test results after referral; ask patients to bring
copies of test results
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Educational Objectives
| The goal of this program is to educate the listener about preventing medical errors. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Describe the magnitude of the problem of medical errors.
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| 2. Identify causes of medical errors.
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| 3. Enhance patient safety by avoiding errors of omission, eg, of indicated immunizations and screening
tests.
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| 4. List methods for eliminating errors in prescribing medication.
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| 5. Educate patients about their medications and therapies in order to avoid potential errors.
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Discussed on This Program
Alendronate sodium [Fosamax]
Carbamazepine [Carbatrol, Epitol, Tegretol, Tegretol-XR]
Cetirizine HCl [Zyrtec]
Diphenoxylate HCl with atropine sulfate [Logen, Lomanate, Lomotil, Lonox]
Isotretinoin (13-cis-retinoic acid) [Accutane]
Metoprolol succinate [Lopressor, Metoprolol Tartrate, Toprol XL]
Quinapril HCl [Accupril]
Ranitidine HCl [Zantac, Zantac 75, Zantac EFFERdose]
Tamsulosin HCl [Flomax]
Terbinafine HCl [Lamisil, Lamisil DermGel 1%]
Suggested Reading
Andrus CH et al: "To Err Is Human": uniformly reporting medica.errors and near misses, a naive, costly,
and misdirected goal. J Am Coll Surg 196:911, 2003; Berwick DM et al: The truth about doctors' handwriting:
a prospective study. BMJ 313:1657, 1996; Chaudhry B et al: Systematic review: impact of health information
technology on quality, efficiency, and costs of medical care. Ann Intern Med 144:742, 2006;
Cohen MR: Trade name, INNs, and medication errors. Arch Intern Med 162:2636, 2002; Fox GN et al:
UpToDate: a comprehensive clinical database. J Fam Pract 52:706, 2003; Mazor KM et al: Disclosure of
medical errors: what factors influence how patients respond? J Gen Intern Med 21:704, 2006; McGlynn EA
et al: The quality of health care delivered to adults in the United States. N Engl J Med 348:2635, 2003;
Molfenter T et al: Reducing errors of omission in chronic disease management. J Interprof Care 19:521,
2005; Stelfox HT et al: The "To Err is Human" report and the patient safety literature. Qual Saf Health Care
15:174, 2006; Surbone A et al: To Err Is Human 5 years later. JAMA 294:1758, 2005; Thurmann PA:
Prescribing errors resulting in adverse drug events: how can they be prevented?. Expert Opin Drug Saf
5:489, 2006; Tierney WM et al: Effects of computerized guidelines for managing heart disease in primary
care. J Gen Intern Med 18:967, 2003; van Gijssel-Wiersma DG et al: Influence of computerised medication
charts on medication errors in a hospital. Drug Saf 28:1119, 2005; White KB et al: Illegible handwritten
medical records. N Engl J Med 314:390, 1986,
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Dr. Coronel-Couto was recorded at Internal Medicine Update 2006, sponsored by the University of Miami Miller
School of Medicine, January 22-27, 2006, in Miami, FL. The Audio-Digest Foundation thanks the speaker and the
sponsor for their cooperation in the production of this program.
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