IOM Advises CPOE, Other Technology for Preventing Medication Errors

Donna Young

To help prevent medication errors, all health care organizations by 2010 should be using electronic prescribing systems and all pharmacies should be able to receive prescriptions electronically, the Institute of Medicine (IOM) said in a report issued on July 20.

Medication errors harm at least 1.5 million patients every year in hospitals, long-term-care facilities, and outpatient clinics, resulting in billions of dollars in extra medical costs, IOM's Committee on Identifying and Preventing Medication Errors said.

On average, a hospitalized patient is subject to at least one medication error per day, the panel said in its report Preventing Medication Errors.

"Studies indicate that paper-based prescribing is associated with high error rates," committee cochair J. Lyle Bootman, dean of the College of Pharmacy at the University of Arizona in Tucson, said during a July 20 media briefing. "Electronic prescribing is safer because it eliminates problems with handwriting legibility and, when combined with decision-support tools, automatically alerts prescribers to possible interactions, allergies, and other potential problems."

About 6% of hospitals have reported having computerized prescriber-order-entry (CPOE) systems, according to the Leapfrog Group, a coalition of public and private purchasers of health care.

Compared with the 2% of hospitals that had CPOE in 2001, the 6% adoption figure is a number to "celebrate," said Leapfrog Chief Executive Officer Suzanne Delbanco. But, she added, that number is "still abysmal."

IOM's Medication Safety Actions for Health-System Pharmacists

  • Monitor medication safety literature and other resources regularly for information related to medication errors and take action to ensure that similar errors will be avoided in the local practice setting.
  • Develop, implement, and follow a medication-error avoidance plan.
  • As part of this plan, establish a routine procedure for double-checking filled prescriptions waiting to be picked up and verifying the accurate entry of data on new prescriptions into computer systems.
  • Monitor error frequencies, and correct system problems associated with errors.
  • Use the show-and-tell counseling method to detect and correct dispensing errors; this should include verification of patient identity.
  • Educate consumers regarding error-prevention techniques and resources (e.g., Web sites such as www.ismp.org, www.safemedication.com, www.ahrq.gov).
  • Pharmacy managers designate a medication safety officer with responsibility for improving the safety of prescription-filling processes.
  • Advocate for a medication safety officer with responsibility for improving medication safety throughout the hospital.
  • Create a safe work environment by optimizing lighting levels, using a magnifying lens or resizable scanned prescription for viewing prescription slips, minimizing distractions, and arranging drug storage areas to call attention to drugs with a high potential for errors leading to patient harm.
  • Advocate for a statewide medication safety coalition to include the state board of pharmacy, pharmacy organizations, practitioners, and consumers.
  • Report errors and near misses to both internal and external medication-error-reporting programs or systems to help others learn how to avoid similar problems.
  • Request resources needed to promote accurate prescription dispensing (clinical decision support, bar-code verification technology, time for counseling patients).
  • Be assertive in requesting resources needed to promote accurate medication processing and dispensing (clinical decision support, bar-code verification technology).
  • Actively pursue a tiered system of clinical alerts that can facilitate better response to serious medication safety issues (e.g., suppress trivial warnings and retain those with a high probability of patient harm).
  • Evaluate and continuously monitor new technologies (e.g., infusion pumps, automated medication-dispensing machines) regarding the risk of introducing medication errors.
  • Regularly make targeted follow-up calls to patients (e.g., those with asthma, chronic pain, hypertension) to assess how they are faring with new medications, learn about any adverse effects or potential adverse drug events (ADEs), and ensure that medications are being taken properly.
  • Work with nurses to make regularly targeted follow-up calls to discharged patients (e.g., those with asthma, chronic pain, hypertension) or use mailed questionnaires to assess how these patients are faring with prescribed medications, learn about any actual or potential ADEs, ensure that medications are being taken properly, and answer any questions patients may have.

Many health systems have postponed CPOE implementation because they are waiting for the prices of the expensive technology to fall, Delbanco said in an interview.

"There's a lot of waiting and seeing that's been going on for years," she said.

News articles about the troubles some high-profile health systems have faced during CPOE implementation, including stories about physicians who refused to use the systems or providers who rebelled against the large investments that their hospitals intended to make in CPOE, have caused other providers to be overly cautious, Delbanco said.

But, she said, those stories are "lessons for how not to implement new technologies" and should be used as a "road map for how to do a successful implementation where the users of the systems are involved from the very beginning."

"There's a variety of reasons why these systems haven't been used," Delbanco said. "But it's unacceptable. When a patient goes into the hospital, they should not be experiencing an error that we have proven tools to prevent."

The know-how and technology to help prevent medication errors has been available in the United States "for decades," she charged.

But, Delbanco said, the question remains how to identify the financial and human resources "to make use of that know-how and technology."

She acknowledged that there are many hospitals that lack the finances and work force to implement CPOE and other technologies that have been shown to prevent medication errors.

But, Delbanco said, other health systems have the resources but are "on the fence. And those are the ones we need to persuade as fast as possible."

Leapfrog promotes the use of CPOE "not only because we see it as the gold standard for intercepting the most common and serious medication errors," she said, "but also because it is intertwined with the need to have an underlying clinical information system, which can provide all kinds of decision support to the caregivers of patients."

Clinical decision-support triggers that should be included in CPOE systems, IOM recommended, include checks for allergies, drug–drug interactions, excessively high dosages, clinical conditions, drug–laboratory issues, and pregnancy-related issues.

Health care organizations, the panel counseled, should adopt other technology that enables practitioners to have access to comprehensive reference information concerning medications and related health data, communicate patient-specific medication-related information in an interoperable format, and assess the safety of medication use through active monitoring.

The IOM committee also promoted the adoption of bar-coded-medication administration (BCMA) and verification technology and electronic health records (EHRs).

"Bar-coded-medication administration technology is something every hospital should be assessing now and most should plan to implement within the next five years," said Kasey Thompson, director of practice standards and quality for the American Society of Health-System Pharmacists (ASHP).

He noted that data from the 2005 ASHP National Survey shows that only 9.4% of hospitals have adopted BCMA technology.

The development and implementation of standardized EHRs, including electronic prescribing functionality, "for use across the entire continuum of care is vastly needed," Thompson said.

"The time has come for meaningful action by the health care community, information technology vendors, government and others to determine what is needed and how to get it done," he said. "Government needs to step up to the plate to provide the infrastructure and funding to ensure that hospitals and other health care organizations have sufficient resources and incentives to implement these continuity-of-care and patient-safety-enhancing systems."

Automated technology can also assist in the transition-of-care process to ensure that medications are accurately and completely reconciled, IOM panelists maintained.

Reconciliation of medications, especially between care settings, is critical to the prevention of medication errors, the IOM committee said.

"In the future, it is inevitable that technologies will serve as increasingly important tools for improving medication safety in all settings, though the specific technologies involved will differ by setting," panelists declared.

Patients should also keep an up-to-date list of their medications and review the list with their providers, the committee suggested.

A large portion of the IOM report focused on the patient's responsibility in the medication-use process.

"The patient is a very critical component," Bootman said. "There are many avenues for error at the patient level. That's why in this report, right up front, we specify that the patient needs to be heavily engaged in this process, communicating with providers and those of us who participate in the process."

Patients should ask questions and insist on answers from their health care providers and make sure that prescribers clearly and fully explain the medication regimen, the committee said.

"Given that there are serious shortfalls between what should be and is, I think helping the consumer be armed with the equivalent of consumer reports or some basic guidelines when they go to get care is highly appropriate," Delbanco said.

But, she added, while the IOM puts a lot of responsibility on patients to be engaged in their own care, it does not mean that institutions should not have protocols and processes in place to ensure that patients are protected from errors and are receiving the best care possible.