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Medication error or professional judgement?

From the June 13, 2001 issue

PROBLEM: Many medication errors are hard to detect, but some that occur during the prescribing phase may be especially elusive and elicit controversy as to whether they are truly an error or an acceptable difference in professional judgement. For example, omission errors are clearly viewed as a pharmacy or nursing problem when either a nurse fails to administer a drug as prescribed or a pharmacist fails to dispense a prescription. But an omission error is less obvious and sometimes debated if a prescriber fails to order medications for which there are evidence-based studies that document a significant reduction in morbidity or mortality. Nevertheless, in the March, 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, the "chasm" clearly refers to the health industry's ineffective application of an ever-expanding base of scientific, technical, and medical knowledge.

In a recent study in Utah, 22% of Medicare patients with congestive heart failure were not prescribed an ACE inhibitor upon discharge from the hospital, with an estimated impact of one unnecessary death every ten days.1 Other gaps in performance included a 34% omission rate for beta blockers and a 10% omission rate for aspirin prescribed upon discharge to patients with myocardial infarction. Even more astonishing, 44% of patients with atrial fibrillation were not discharged on warfarin, which could translate into one unnecessary stroke every two weeks. Another recent study, cited in the Journal of the American Medical Association, showed that widespread warnings about medications proved ineffective in changing prescribing practices.2 In the US and Italy, improper PROPULSID (cisapride) prescriptions did not decline in the year following an extensive 1998 warning to restrict its use in cardiac and pulmonary patients and to avoid potentially dangerous combinations with other drugs. Likewise, improperly monitoring the effects of drugs such as REZULIN (troglitazone) has resulted in voluntary withdrawal from the market of otherwise valuable medications.

SAFE PRACTICE RECOMMENDATION: Pharmacists can play a pivotal role in the application of evidence-based knowledge by actively reviewing applicable research, disseminating the information to the medical staff, and establishing clinical monitoring functions for selected outcomes. For example, recent research shows that prescribing aspirin to diabetic patients will dramatically decrease cardiovascular incidents.3 Daily pharmacists' interactions with prescribers should be face-to-face to assist in the selection of appropriate drug therapy, including those prescribed at discharge. Pharmacists should document interventions and share aggregate results with prescribers to generate ideas for improvement (e.g., establish prescribing/dosing guidelines, drug protocols, preprinted orders, etc.). As new evidence dictates, algorithms or protocols should be established to guide prescribing during hospitalization and upon discharge. Pharmacists also need to sharpen their focus on applying evidence-based approaches to treating chronic conditions, not just presenting conditions. A limited number of chronic conditions (e.g., diabetes, asthma, hypertension, etc.) account for the majority of illness, disability and death in the US. Chronic drug therapy monitoring may require direct interaction with primary care physicians who may not be following the patient in the hospital. Finally, computerized prescriber order entry (CPOE) can be a powerful vehicle to drive the application of evidence-based knowledge. But remember, physicians and pharmacists must ensure that the CPOE system incorporates the necessary rules to assist with evidence-based prescribing (e.g., automatic query about warfarin in patients with atrial fibrillation, etc.).

References: Bateman K. Your zipper is down. Bul.Utah Med Assoc. 2000;47; 2). Raschetti R, Maggini M, Da Cas, R et al. Time trends in the coprescribing of cisapride and contraindicated drugs in Umbria, Italy. JAMA 2001;285:1840; 3). Colwell JA. Aspirin therapy in diabetes. Diabetes Care 1997;20:1767- 1771

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