Hospitals have switched from handwritten prescriptions and pills in Dixie cups to computerized order entry and robotic drug dispensing, but one thing hasn’t changed over the past two decades: the small but severe risk of injuries and deaths from medication errors.
In a new report, Minnesota hospitals disclosed four deaths and 10 serious injuries related to medication errors in the 12-month period ending last Oct. 6. That’s the highest total in 12 years of “adverse event” reporting in Minnesota, which remains one of only five states to publicly disclose hospital errors as part of a concerted effort to prevent them.
“One is too many,” said Dr. Beth Thomas, interim chief medical officer for Fairview Health Services, which reported five medication errors at the University of Minnesota Medical Center last year and a sixth at Southdale Hospital in Edina.
Disabling or fatal medication errors have vexed hospital officials statewide, because they can occur at so many different points along the prescription pipeline.
Among the other 28 errors tracked by the Minnesota Department of Health, some have been easier to define. Hospitals, for example, had fewer incidents in which objects were left inside surgery patients, because their collaborative reporting identified lab sponges and device fragments as culprits. Only 22 such cases occurred last year, compared with 37 in 2011.
In all, last year’s report included 316 adverse events, a slight increase from 308 in 2014, according to the new report. Fatal patient falls declined from 79 in 2014 to 67 last year, but losses of irreplaceable biological specimens increased from 20 to 27.
Among medication errors, one occurred when a drug was given by a shot rather than intravenous pump. Another involved a prescription added after a patient had already received a take-home drug list. Another involved a medication that was halted before surgery but not restarted.
“There are many transition points” in prescribing, said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association. “The medication is ordered by the physician, so there is room for human error there. The medication is then checked off by the nurse … and then evaluated by the pharmacist.”
Even precise robotic dispensers can be fooled if people restocking them aren’t separating their Pitocins from their Petrissins.
But patterns are starting to emerge now that the state has multiple years of medication errors to compare. Steve Meisel, Fairview’s director of patient safety, examined the fatal or disabling errors reported statewide in the past three years and found that nearly half involved blood-thinners or cardiac drugs.
Seven of the 14 medication-related injuries or deaths last year occurred when patients had already gone home or to long-term care facilities, indicating that errors were happening as hospitals double-checked and adjusted medications after discharge.
A case in point is a lawsuit filed Feb. 3 against Mayo Clinic by the family of Bertha Nelson, who suffered kidney damage and died June 9, 2014, after her doctors allegedly failed to follow their colleagues’ recommendations and reduce her antibiotics when they discharged her.
Data from MMIC, which provides medical professionals with liability insurance in Minnesota and 15 other states, shows that medications accounted for about 8 percent of all malpractice claims from 2010 to 2014, and $26 million of the company’s judgments or payouts.
Management of blood-thinners is particularly challenging. Patients who receive stents to prop open clogged blood vessels need them to prevent new blockages from forming, but are at risk of dangerous bleeding if they remain on them during surgeries.
“It’s like trying to put your foot on the brake and the gas at the same time,” said Dr. Darin Willardsen, chief medical information officer for CentraCare Health. The system’s St. Cloud Hospital reported two serious injuries from medication errors last year, both related to blood-thinners.
CentraCare responded with a “hard stop” in its electronic medical record system, requiring surgeons to justify taking patients off blood-thinners and weigh the risk of clotting.
Hospitals aligned with CentraCare and with Allina Health in the Twin Cities now have pharmacists in their emergency rooms to interview patients and check their prescription histories. On average, these visits result in five adjustments to patients’ documented drug regimens, such as correcting outdated information or avoiding harmful drug combinations.
Allina didn’t report any medication adverse events until 2014, when two occurred at United Hospital in St. Paul and St. Francis Regional Medical Center in Shakopee.
None was reported this year, and medication problems in general have declined since the pharmacist visit program started last summer, said Jill Strykowski, pharmacy director for Allina’s Mercy Hospital.
Bar-coding a safety net
The U’s hospital has accounted for 22 of the 86 fatal or disabling medication errors in the 12 years of adverse event reporting. That in some ways is expected, Thomas said, because the hospital is the state’s largest and treats complicated and heavily medicated patients.
University uses a secure dispensing system that prevents patients from receiving others’ medications and bar-coding that requires nurses to check that prescriptions are matched to the right patients. The hospital’s electronic medical record system also automatically warns caregivers if they prescribe drugs to which patients are allergic, or in doses that appear excessive.
However, the hospital also discovered that well-intended warnings from patients’ monitors and record systems can cause “alert fatigue,” because they can be oversensitive and call attention to unimportant issues. The hospital reduced alerts by 17 percent and believes it will allow staff to focus on the meaningful ones, including those about high-risk drugs.
“It’s always a fine balance,” Thomas said. “We want to have alerts there to make sure people are aware of what they are doing. At the same time, you don’t want so many alerts that people just turn them off.”