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
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