Depending on where you read it, medical errors and all the secondary problems they can cause are costing providers anywhere from more than $17 billion to upwards of $1 trillion. A new study from the Pennsylvania Patient Safety Authority seeks to shed light on what is causing medication orders to get mixed up and go to the wrong patient. The reasons are many some subtle, some less so. And some entrepreneurs and enterprising hospital staff are tackling the issue in different ways.
Although the study points out that these errors can happen anywhere and be made by anyone, more commonly than not, 43 percent happen in administration There were some pretty diverse reasons for these errors such as:
- Wrong patient chosen from an automated dispensing cabinet.
- Ignoring protocol for identifying patients by relying on the patient or family to verify the patient’s identity.
- Mixing up patients sharing a room.
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About 38 percent of the medication errors stemmed from transcribing or transferring a paper medication order to an electronic or paper medication administration record. Most of these mistakes involved transferring the information from the wrong chart.
Prescribing errors were mostly caused by ordering a medication on the wrong chart and accounted for 12 percent of these mistakes. In other cases, a physician mistakenly ordered medications for a patient’s wife who was staying in the same room.
Dispensing was responsible for the fewest errors — about 5 percent. Medication was delivered to the wrong patient’s bin or the wrong patient’s label was put on the medication, for example.
Better patient engagement and computerized prescriber order entry (CPOE) are two critical ways to reduce these errors, the study said. In many cases, the study said, patients and their families caught errors in time by spotting, for example, the wrong medication or wrong name on an IV. And true to form, although the Patient Safety Authority’s study acknowledged that CPOE has been shown to greatly reduce wrong patient medication errors, it can actually cause them too.
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Scannable bracelets are one proposal that some entrepreneurs are developing and actually was proposed in a competition at Penn Medicine to come up with ways to improve the patient experience. Hospitals in Japan, Singapore and Hong Kong are using QR codes.