Drug safety loophole persists

  • Article by: WARREN WOLFE , Star Tribune
  • Updated: November 10, 2011 - 10:52 PM

Nursing homes are exempt from law requiring e-prescription use. Hospitals and clinics are slow to meet state requirement.


Registered nurse Candace Trondson administered daily medication for treatment of Parkinson’s disease to Lyngblomsten Care Center resident Paul Samuelson, 90. The St. Paul nursing home is instituting a new computerized medication system expected to help reduce medication errors.

Photo: Jim Gehrz, Star Tribune

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Last January, Minnesota became the first state to require doctors and hospitals to use "e-prescriptions'' in an effort to reduce costly, dangerous medication errors.

But the law has a gaping loophole -- as Minnesotans learned with the death of Darlene Felt, 84, from a massive potassium chloride overdose when staff at her nursing home misread a physician's handwritten order.

The state's 384 nursing homes, with about 29,000 medically frail residents, are exempt from the law.

"We would like to be part of the mandate but, so far, none of the millions in state and federal money for electronic medical records systems has gone to long-term care," said Gayle Kvenvold, CEO of Aging Services of Minnesota, the state's largest nursing home trade group.

"Everybody knows people die from poor handwriting and transcription errors," said Deb Holtz, Minnesota's ombudsman for long-term care. "How is it we're trying to practice 21st century medicine with 1950s technology?"

Minnesota doesn't track the number of prescription errors in nursing homes, but a 2006 report by the National Academy of Sciences estimated that about 800,000 medication-related injuries occur in nursing homes every year.

Despite the state's e-prescription law, only 39 percent of hospitals and 61 percent of clinics send prescriptions electronically, according to Health Department data to be published in January.

Pharmacists do better, with 88 percent -- 956 of 1,089 pharmacies -- processing at least one e-prescription a month.

Minnesota doctors handled 1.4 million prescriptions electronically in August -- just one-third of the total in an average month.

In frustration, some nursing homes ask pharmacists to fax them printouts of a doctor's e-prescription to clear up questions left by poor penmanship.

Now, some nursing homes are building their own internal electronic medical records systems to better track care of residents. But there is no off-the-shelf program they can buy allowing them to exchange electronic records with doctors and pharmacists.

Complicated and expensive

Quite beyond e-prescriptions, by 2015 all Minnesota health care providers -- except nursing homes -- must have electronic systems that can communicate with other providers for the patient's full range of medical records. The goal is to increase accuracy, improve patient care, eliminate millions of hours of clerical tasks and, ultimately, save money with a safer, more efficient system.

"We're making progress, but it's expensive and complicated to set up these systems," said Marty LaVenture, who coordinates the effort for the Health Department.

Some providers are installing the comprehensive record systems required by 2015 and avoiding the extra expense of just an e-prescription system, he said.

Darlene Felt's death last December at Bethany Home in Alexandria, Minn., was a rare event, experts agree -- so rare that Minnesota Department of Health investigators cannot say how often it occurs. In January 2010, a transcription error caused another woman to die after nursing home workers failed to give her a medication for eight days.

In Felt's case, the Alexandria home was cited for failing to check if the handwritten prescription was for 8 or 80 milliequivalents of potassium chloride twice a day. The Minnesota Board of Pharmacy is investigating to determine why the pharmacist did not call the doctor.

Confusion is common over handwritten medical records and doctors' orders, said Jule Poechmann, administrative support nurse at Lyngblomsten Care Center in St. Paul.

"We're always checking those out, lots of phone calls every day," she said.

Small steps to the future

Nurse Candace Trondson pushed her medication cart from room to room at Lyngblomsten last week, doling out prescriptions the way it's been done for years, consulting her marked-up monthly printout of medicines and checking off those that had been taken.

But a few yards away, other employees in a computer class took the first step toward the next generation of electronic control of medications. Within months, Trondson's med cart will come with an attached computer that tells her what to give the resident and warning if a medication is missed.

"It won't solve the handwriting issue -- we'll still have to call the doctor. But it eliminates many potential transcription errors," Poechmann said.

Across the Mississippi River, Augustana Care Center in Minneapolis has had that computerized med-dispensing system in place for a year and has taken it a step further.

Eight carefully screened Augustana employees now can use computers to read sensitive medical records in the Allina Health System, and within weeks will start reading those of Hennepin County Medical Center.

'Never a good excuse'

"We can't send out, and they can't send to us," said nurse Tracy Christofilis, clinical director of a broad program to improve care at Augustana. "But we can read a patient's chart and med orders. It's still a little clunky, but it's better."

Even once adopted, electronic prescriptions won't eliminate human error, cautioned Cody Wiberg, head of the state Pharmacy Board. He hears weekly from pharmacists about physicians using computers but clicking on wrong drugs or dosages.

Still, more e-prescriptions should reduce the risk of errors like the one that caused Darlene Felt's death, officials say.

"We'll never get to zero errors," Poechmann said. "But that should be our goal. There is never a good excuse for a medication error."

Warren Wolfe • 612-673-7253

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