Published on May 7, 2008
IOM Report on Preventing Medication Errors: IOM Report on Preventing Medication Errors R. SCOTT EVANS, M.S.,Ph.D. LDS Hospital/Intermountain Healthcare University of Utah Salt Lake City, Utah, USA Background: Background The “To Err Is Human” report in 2000 by IOM increased national and international attention about the number of patients experiencing adverse events during medical care. Medication related adverse events represented the single leading cause. Slide3: Many ADEs resulted from medication errors which occur at all stages of the medication process. The report focused mainly on the inpatient setting. It has become clear that medication- related issues are a major problem outside the hospital as well. Slide4: The Crossing the Chasm report provided an extensive vision for improving quality in this country. The Patient Data Safety Standards report discussed how this might be achieved. Both of these committees addressed quality and safety but did not target medication safety. Slide5: In 2004, the U.S. Congress mandated CMS to sponsor the IOM to carry out a comprehensive study of “drug safety and quality issues” in order to provide a blueprint for system-wide change. Slide9: Error: The failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning). An error may be an act of commission or an act of omission. Medication error: Any error occurring in the medication use process. Adverse drug event: Any injury due to medication. Slide15: At least 1.5 million preventable ADEs occur each year in the United States. Hospital: 380,000-450,000. Ambulatory Care: 530,000 Long-term care: 800,000 Likely underestimates. Slide16: On average a hospital patient is subject to at least one medication error per day. Considerable variation in error rates across facilities. At least a quarter of all medication- related injuries are preventable. Slide17: Nursing Home Care More than 1.6 million residents of nursing homes in U.S. The long-term care arena is in need of research including incidence and characterization errors. Levels of medication use are high and patients are at particular risk for ADEs (Gurwitz et al., 2000, 2005). As many as half of all ADEs in the nursing homes may be preventable. Slide18: Inadequate pain management documented in nursing homes, 45–80% of residents experience unrelieved pain (American Geriatric Society, 2002). Studies indicate that 26% of nursing home residents overall and 30% of those with cancer have daily pain, and 25% receive no analgesics (Bernabei et al.,1998; Won et al., 1999, 2004). Slide19: Findings – ADE Costs Hospital: extra hospital costs of $5,857, annual cost of $2.3 billion in 1993 dollars or $3.5 billion in 2006 dollars. Outpatient: The cost in 2000 per preventable ADE was estimated at $1,983, and national annual costs were estimated at $887 million. Long term care: 800,000 preventable ADEs annually…little data on costs. Slide20: Lack of Information Millions of Americans take prescription drugs each year without being fully informed by their providers about associated risks, contraindications, and side effects. When clinically significant medication errors do occur, they usually are not disclosed to patients or their surrogates unless injury or death results. Pharmacy leaflets inadequate and not consistent. Slide21: Drug Naming, Labeling, and Packaging Problems • Brand names and generic names that look or sound alike • Different formulations of the same brand or generic drug • Multiple abbreviations to represent the same concept • Confusing word derivatives, abbreviations, and symbols • Unclear dose concentration/strength designations • Cluttered labeling; small fonts, poor typefaces, no background contrast, overemphasis on company logos • Inadequate prominence of warnings and reminders • Lack of standardized terminology Slide22: Barriers For Consumers and Providers Knowledge deficits, such as, patients lacking sufficient education about their medications, and providers lacking the latest pharmacological knowledge about particular medications; Practical barriers, such as patients being unable to pay for their medications, and providers having to operate burdensome prescribing arrangements required by payers. Attitudinal factors, such as the patient and provider having different cultural and belief systems about the use of medications. Slide23: ELECTRONIC PRESCRIBING AND MONITORING FOR ERRORS IN ALL CARE SETTINGS ARE ESSENTIAL It is almost impossible for health care providers to have current knowledge of every medication they prescribe. Provide decision support for prescribing clinicians; CPOE, Internet, PDAs. Bar coding and smart infusion pumps. Pharmacist on rounds and in nursing homes. Slide24: Recommendations Slide26: IMPROVED PROVIDER-PATIENT COMMUNICATION Shift away from a provider-centric model of care. Consumers (and surrogates) should be empowered as partners, with appropriate communication, information, and resources in place to support them. Consumers and providers should know and act on patients’ rights; providers should engage in meaningful communication about the safe and effective use of medications and at multiple points along the medication-use process. Government and other participants should improve consumer-oriented written and electronic information resources. ConsumersHow to help avoid medication errors.Personal/Home Care: Consumers How to help avoid medication errors. Personal/Home Care Maintain a list of prescription drugs and OTCs. Take list whenever visit a healthcare provider. Be aware of where to find educational material in the community and on the web. ConsumersHow to help avoid medication errors.Pharmacy: Consumers How to help avoid medication errors. Pharmacy Verify name of drug and directions on prescription match those from pharmacy. You can review your medication list with the pharmacist. You have the right to counseling by the pharmacist if you have any questions. You have the right to receive any written information about you medications. ConsumersHow to help avoid medication errors.Ambulatory/Outpatient Care: Consumers How to help avoid medication errors. Ambulatory/Outpatient Care Have prescriber write down or provide drug info; drug name, dosage, how often to take it. Have prescriber explain how to take drug; i.e. with food. Ask about any side effects and what to do if experience them. ConsumersHow to help avoid medication errors.Inpatient Care: Consumers How to help avoid medication errors. Inpatient Care Ask doctor or nurse what drugs you are being given. Do not take drug without being told the purpose. Right to have a surrogate present when can’t monitor medications yourself. Prior to surgery, ask about preop drugs or drugs you should stop taking. Prior to discharge, ask for list of drugs you should be taking at home and understand their use. Slide31: Physicians, nurses and pharmacists • Review the patient’s medication list routinely…especially during transitions. • Review different treatment options. • Review the name and purpose of the selected medication. • Discuss when and how to take the medication with the patient. Slide32: Physicians, nurses and pharmacists (continued) • Discuss drug-drug, drug-food, and drug- disease interactions. Discuss important and likely side effects and what to do about them. • Review the patient’s or surrogate’s role in achieving appropriate medication use. • Review the role of medications in the overall context of the patient’s health. Slide36: Implement active monitoring programs to determine rates and measure improved medication safety. Erase the stigma. Computer detection. Reconcile medication orders between transition points, especially between care settings such as the hospital and outpatient setting. Need electronic medical records…Katrina example. Will be a challenge for long term care due to limited resources and increasing demand. Slide37: Adopting a Safety Culture Organizational commitment to continually seek to improve safety. Senior management must also authorize the investment of resources in technologies that have been demonstrated to be effective but are not yet widely implemented in most organizations, such as computerized provider order entry systems and electronic health records. Write prescriptions electronically by 2010 and all pharmacies to be able to receive them electronically, also by 2010. All prescribers should have plans in place by 2008 to implement electronic prescribing. Slide38: ADDRESS KNOWLEDGE DEFICITS The correct dose of the drug. Majority of prescriptions written for children are off label. Patients over age 80. Renal dysfunction. Multiple co-morbidities Publication of clinical studies in a national repository to advance medication safety. Lack of documentation of medication use of free samples. Slide39: Research Congress should allocate necessary funds and AHRQ should take the lead with CMS, FDA and NLM to coordinate a broad research agenda on the safe and appropriate use of medications across all care settings, covering research methodologies, incidence rates by type, severity, and costs of medication errors, reporting systems, and in particular, further testing of error prevention strategies. Slide40: Summary Slide43: IOM committee identified enormous gaps in the knowledge base with regard to medication errors. Current methods for communicating information about medications are inadequate and contribute to the incidence of errors. Likewise, incidence rates of medication errors in many care settings, the costs of such errors, and the efficacy of prevention strategies are not well- understood. Slide44: The present report makes clear that with regard to medication errors, we still have a long way to go. The current medication process, prescribing, dispensing, administering, and monitoring, is characterized by many problems and issues. Each of the steps in the process needs improvement and further study. Slide45: Prevent Medication Errors Slide46: The National Academy of Sciences was created by the federal government in 1863 to be an adviser on science and technology. However, the Academy and its associated organizations (e.g., the Institute of Medicine) are private, non-governmental, organizations, do not receive direct federal appropriations. Studies for the government are funded out of appropriations made available to federal agencies. Most of the studies carried out by the Academy complex are at the request of government agencies. Slide48: The IOM is an independent body, with unpaid experts who author most reports. Each report goes through a rigorous and formal peer review process, findings and recommendations must be evidence-based whenever possible else noted as expert opinion. Because the IOM is not a governmental organization, experts and committees have a greater variety of options to conduct the studies. In particular, although many meetings are open to the public, the committee may deliberate among themselves, and is not obligated to conduct all their work in a public forum. Slide49: Committees are the deliberating and authoring bodies for IOM reports. The committee is formed by identifying the expertise and perspectives necessary to address the study topic, soliciting and receiving nominations for candidates from a wide and extensive number of sources, presenting a proposed slate and alternatives to the IOM leadership group, receiving approval from the IOM President. A process of seeking to identify biases and potential conflicts of interest takes place and may disqualify individuals.