The Institute of Medicine (IOM) published findings in 1999 on the quality of healthcare in America. That report, "To Err Is Human: Building a Safer Health System," concluded that as many as 7000 Americans die from medication errors each year.^[1] In July 2006, the IOM released a new report, "Preventing Medication Errors," stating that the frequency of medication errors and related injuries was still a serious concern.^[2]

A common question that arises is: "What drugs are most often involved in medication errors?" Matthew Grissinger, RPh, FASCP, is a medication safety analyst with ISMP, the nation’s oldest voluntary drug error reporting program, located in Huntingdon, Pennsylvania. His session on "The Top 10 Adverse Drug Reactions and Medication Errors" drew an audience that filled the meeting hall.^[3]

Grissinger first referred to a study that identified the 10 drugs most commonly implicated in adverse events requiring treatment in a hospital emergency department (ED).^[4] The study also documented the frequency with which each of the 10 drugs was involved:

1. Insulin (8%);
2. Anticoagulants (6.2%);
3. Amoxicillin (s) (4.3%);
4. Aspirin (2.5%);
5. Trimethoprim-sulfamethoxazole (2.2%);
6. Hydrocodone/acetaminophen (2.2%);
7. Ibuprofen (2.1%);
8. Acetaminophen (1.8%);
9. Cephalexin (1.6%); and
10. Penicillin (1.3%).

Unintentional overdoses made up 40% of these ED visits, representing the most prevalent mechanism of injury by far. Other mechanisms included side effects and allergic reactions. Some of the drugs on this list are especially common (eg, hydrocodone and amoxicillin), so the sheer volume of prescriptions written is a major factor.

The elderly also play a key role in this issue, as they account for 34% of all written prescriptions. The average number of prescriptions for an elderly person in the United States in 2000 was 28.5 per year. That number is estimated to reach 38.5 by the year 2010. Almost a quarter million seniors are hospitalized every year due to reactions between prescription and over-the-counter (OTC) medications.

Common misuses that lead to adverse drug events are taking incorrect doses, taking doses at the wrong times, forgetting to take doses, or stopping the medication too soon (all nonadherence issues). An example of commonly misused medications can be seen with arthritis therapies. Seventy million Americans suffer from arthritis and joint pain, which translates into 30 million people taking nonsteroidal anti-inflammatory drugs, either prescription or OTC. Misuse of these drugs leads to 103,000 hospitalizations and 16,000 deaths per year. Unnecessary use of nonsteroidal anti-inflammatory drugs also increases avoidable side effects, such as dyspepsia, peptic ulcer, and gastrointestinal bleeding.

Another high-volume prescription class is the antibiotics. This group represents significant inappropriate prescribing: Twenty-three million antibiotic prescriptions are written for colds, bronchitis, and upper respiratory infections each year, Grissinger said, despite the fact that antibiotics don’t kill viruses.

Top 10 Medications Involved in Drug Errors

A somewhat different top 10 list identifies medications that are most commonly misused or mishandled in some way by healthcare professionals. This list is based on information from the United States Pharmacopoeia (USP), which maintains a database of medication errors that are reported anonymously. The figures represent drug errors associated with acute hospital care^[5]:

1. Insulin (4% of all medication errors in 2005);
2. Morphine (2.3%);
3. Potassium chloride (2.2%);
4. Albuterol (1.8%);
5. Heparin (1.7%);
6. Vancomycin (1.6%);
7. Cefazolin (1.6%);
8. Acetaminophen (1.6%);
9. Warfarin (1.4%); and
10. Furosemide (1.4%).

Hospitals and healthcare systems use the USP database to track medication errors and identify trends. Drug errors are defined as unintentional acts committed by healthcare providers involving medications. Grissinger noted that comparable data are unavailable for outpatient care.

The number 1 error-prone medication is insulin. In fact, a 1998 ISMP study found that 11% of all serious medication errors involve insulin misadministration.^[6] Errors include mixing up products with similar packaging (look-alike products); confusing generic listings on computer databases; similarity in names (eg, Humalog and Humulin); and most importantly, confusing the abbreviation "u" for units with the number 0. ISMP reports that these errors have been occurring for over 30 years.

The second drug on this list is morphine, which can be extrapolated to include all opioids, Grissinger said. Similar names for some of these drugs often cause confusion, such as:

• Avinza and Evista;
• Morphine and hydromorphone;
• Oxycontin and MS Contin;
• Hydrocodone and oxycodone; and
• Oxycodone and codeine.

In the community pharmacy, these drugs often are stacked close together in a locked area, and many have similar packaging, making it easy to grab the wrong one when dispensing. Another common mistake is mixing up oxycodone with oxycodone ER (extended release), especially in handheld device order entry.

Morphine oral solutions cause many problems because of the multiple concentrations that are available, all stored close to each other. For example, it would be easy to confuse "mL" with "mg"; using 5 mL of morphine 20 mg/mL (100 mg) instead of the prescribed 5 mg (0.25 mL) would lead to overdosing the patient. Alternatively, an intended dose of 1 mL of morphine 20 mg/mL (20 mg) might be given as 1 mL of 10 mg/5 mL (2 mg), thus underdosing the patient. Grissinger also reported a case in which Avinza (morphine ER caps) 30 mg was misinterpreted and dispensed as "qid" (4 times daily) instead of "qd" (once daily), causing a near-fatal overdose.

Acetaminophen is another drug on the error list that causes many problems. It is available in many different strengths, and various measuring devices are available for dispensing it. In addition, it is found in many combination medications, both prescription and OTC. Prescription labels of combination products with acetaminophen can be very confusing for the patient. For example, hydrocodone 10/650 has 650 mg of acetaminophen, but many patients would not know how to interpret that.

Grissinger reminded the audience that acetaminophen can be toxic, even though it is sold OTC. A recent study showed that acetaminophen-induced liver toxicity accounts for more than 40% of US cases of acute liver failure.^[7]

Antibiotics are the next big group of drugs associated with medication errors. As with opioids, the liquid dose concentrations increase the risk for mistakes. Confusion over measurements in "mL" vs "tsp" (teaspoons) can cause a 5-fold overdose or underdose if undetected. In one case, for example, azithromycin suspension was dispensed with directions to take 2.5 tsp daily (equivalent to 12.5 mL) instead of the intended 2.5 mL daily, Grissinger reported. The entire contents of the bottle were administered according to the labeled instructions, and the child developed diarrhea.

Reconstituting antibiotics can also be problematic. Pharmacists have mistakenly reconstituted antibiotic suspensions with alcohol instead of distilled water.

System Errors May Interfere With Individual Efforts

Most healthcare professionals have learned the "5 rights" of safe medication use: the right patient, the right drug, the right time, the right dose, and the right route of administration.

However, in his book Medication Errors, Michael Cohen wrote that these "rights" focus on individual performance and can overlook system errors. Examples of system errors are poor lighting, inadequate staffing, handwritten orders, doses with trailing zeros, and ambiguous drug labels. All of these can prevent healthcare professionals from verifying the 5 rights.^[8]

Experts at ISMP have identified 10 key "system" elements that most influence medication use, reported Donna Horn, RPh, DPh, ISMP Director, Patient Safety - Community Pharmacy. Systems factors play a major role in increasing the likelihood that an individual will make an error. Deficiencies in any of these system elements can lead to medication errors^[9]:

1. Patient information (age, weight, allergies, diagnoses, and pregnancy status);
2. Drug information (up-to-date information readily available);
3. Communication (collaborative teamwork between all healthcare members and the patient);
4. Drug labeling, packaging, and nomenclature (limit look-alike and sound-alike drug names, confusing packaging);
5. Drug standardization, storage, and distribution (restricting access to high-alert drugs);
6. Medication delivery device acquisition, use, and monitoring;
7. Environmental factors (poor lighting, cluttered work spaces, noise, interruptions, nonstop activity, and deficient staffing);
8. Staff competency and education;
9. Patient education; and
10. Quality processes and risk management (systems are needed for identifying, reporting, analyzing, and reducing the risk for medication errors with a nonpunitive culture of safety).

When an error occurs, it is tempting to blame individuals, Horn said. A "systems approach," however, looks at the whole system rather than individual errors. For instance, failures in the design or implementation of systems can lead to excessive reliance on memory, lack of standardization, inadequate access to information, and poor work schedules. Thus, with a systems approach, accountability is expanded to include anyone who had any influence over the error, setting the stage for broader solutions.

How Can We Prevent Medication Errors?

Nearly half of all adverse drug events have some form of "preventability," and many do not represent errors of commission but, rather, errors of omission. This implies a failure on the part of someone (pharmacist, physician, patient, or the interactions between these groups) to detect certain factors that most likely led to the adverse event. These factors include:

1. Failure to detect a disease state contraindication to the drug therapy;
2. Failure to detect a significant drug interaction;
3. Failure to detect a significant drug allergy;
4. Failure to prescribe the correct dose for a specific patient;
5. Failure to monitor drugs with narrow therapeutic indexes; and
6. Patient knowledge deficits.

Many of these can be avoided by spending a few minutes counseling the prescriber and/or the patient. Communication is key, Horn said. Barriers to effective communication include illegible handwriting, abbreviations, verbal orders, ambiguous orders, and fax or ePrescribing problems.

When communicating with prescribers, pharmacists should identify the issues clearly and concisely, said Marialice Bennett, RPh, FAPhA, Professor and Pharmacy Director of the University Health Connection at Ohio State University in Columbus, Ohio.^[10] She offered these suggestions for such discussions:

• Outline the specifics of the problem;
• Keep focused on the patient;
• Provide possible solutions;
• Ask for prescriber feedback; and
• Document the final decision.

Conflict can lead to poor communication, which can hinder the discovery of medication errors, she said. Conflicting opinions about patient care should be handled objectively and professionally. The ISMP recommends that healthcare organizations create a code of conduct that encourages behaviors supportive of team cohesion, staff morale, and sense of self-worth and safety.

Physician-patient relationships Business Editors/Medical Editors BOSTON–(BUSINESS WIRE)–May 17, 2007–As part of its ongoing commitment to patient safety, ProMutual Group, a leading provider of medical liability insurance in the Northeast, is pleased to announce that on behalf of its insured physicians, it has negotiated a discount on annual subscriptions to EmmiPrep(TM), an innovative, web-based, patient education and risk management tool. The reduced cost of Emmi will be effective immediately for all policyholders that purchase an annual subscription.

Developed by Emmi Solutions, LLC, the innovative Emmi system is designed to help healthcare providers improve the quality and reduce the costs of healthcare. At the heart of the Emmi system are engaging, interactive programs that help patients and their families understand what to expect before, during and after a medical procedure. The Emmi program’s interactive nature allows patients to ask specific and confidential questions of their physician and alerts physicians to specific concerns the patient may have. This important attribute further enhances communication and strengthens the physician-patient relationship. The program also provides detailed documentation of each patient interaction with the program and provides physicians with a powerful risk management tool to ensure patients understand their role in ongoing care before and after a procedure. 

We are constantly looking for new and innovative ways to promote patient safety," said Maureen Mondor, vice president of risk management for ProMutual Group. "Emmi provides an excellent means of educating patients, improving the informed consent process and mitigating risk. We think Emmi will be an ideal complement to ProMutual Group’s ongoing efforts to provide superior risk management services to our insureds so they can better meet the needs of patients and the challenges of healthcare practice today."

Studies indicate that patients who fully understand what to expect from medical procedures are more satisfied with the outcomes and less likely to file medical malpractice claims. Not surprisingly, a 2006 survey conducted by Emmi Solutions found that of the 18,000 patients who had viewed an Emmi program, 96 percent developed a better understanding of their procedure. Additionally, 79 percent of patients found that the program provided new and important information and 85 percent reported that the program increased their confidence in their doctor and comfort level with the procedure.

"I want to do everything I can to increase patient safety and reduce risk in procedures that I perform," said Dr. Murray Goodman, an orthopedic surgeon in Salem, Mass. "A large part of that is educating patients and helping to bring their expectations in line with reality. I always have an informed consent conversation with my patients, but using Emmi helps many of my patients more fully understand the proposed procedure, the reason behind it, and its risks and benefits."

By utilizing Emmi in their practices, ProMutual Group policyholders will be able to build relationships with patients, further improve patient satisfaction and increase patient safety.

"We are pleased to be collaborating with ProMutual Group in introducing Emmi to the physicians they insure," said Jordan Dolin, vice chairman of Emmi Solutions, LLC. "Emmi is a unique, innovative system that has been adopted by some of the most progressive healthcare providers in the country. We think it’s a great fit for ProMutual Group and its insureds to enhance the healthcare experience for everyone involved."

For more information about the Emmi Solutions program, to schedule an interview with a ProMutual Group representative or speak with a physician currently utilizing the system, please contact Nina Akerley at ProMutual Group via telephone number (617) 946-8665 or by email at nakerley@promutualgroup.com.

About ProMutual Group

ProMutual Group is the largest provider of medical malpractice liability insurance in New England, insuring more than 18,000 physicians, surgeons, and dentists as well as a large number of hospitals, health centers and clinics. It is one of the top 10 medical liability insurance providers in the country based on direct written premium. ProMutual Group has more than $2 billion in admitted assets, over $500 million in policyholder surplus, and nearly $340 million in direct written premium. ProMutual Group has a Best’s Rating of A- (Excellent), and is a leader in providing risk management and claim services.

Based in Massachusetts, ProMutual Group member companies also operate in Connecticut, Maine, New Hampshire, New Jersey, Pennsylvania, Rhode Island and Vermont. ProMutual Group distributes its products through independent agents. For more information, visit ProMutual Group’s web site at www.promutualgroup.com.

About Emmi Solutions

Emmi Solutions, LLC is the producer of the Emmi healthcare communication system, helping health organizations connect more intimately and effectively with patients and their families. In a field where trust and good communication is critical to quality and safety, Emmi is highly regarded as a one-of-a-kind intervention that clarifies complex information using a conversational voice to engage patients and affect behavioral change.

Created in 2002 by a surgeon and a computer game designer, Emmi facilitates physician-patient communication by providing multimedia programs to help patients understand what to expect. Whether it’s preparing for a procedure, living successfully with a medical device, or helping people manage a chronic disease, every detail of the Emmi system is designed with a single goal in mind: to improve quality by helping patients, their families and caregivers take an active role in their care. Better-informed patients who are engaged in their care drive benefits that cascade across all healthcare organizations and interests.