May 24, 2005
Computer Systems Aren’t Reducing Medical Errors
Study finds continuing high rates of mistakes in hospitals
HealthDay News -- Hospitalized patients expect their care to be safe, but two new reports suggest hospital computer systems designed to weed out dangerous medical errors aren't living up to expectations.These in-hospital computerized medication entry systems -- software that helps doctors, nurses and pharmacists track drug prescription and use -- were supposed to help improve safety. But a new study shows medication errors continuing at an alarming rate even when such software is in use.
"In one of the most highly computerized hospitals in the world, we found a very high rate of adverse drug events in hospitalized patients," said lead researcher Dr. Jonathan R. Nebeker, a physician at the Veterans Administration Salt Lake City Health Care System.
In their study, Nebeker's team found 483 clinically significant adverse drug events occurring in 937 Veterans Administration hospital admissions. "That's about 25 percent of all patients," Nebeker said. He added that computer systems used in these hospitals were specifically designed to prevent medication errors.
Nine percent of these adverse events caused serious harm, the researchers report, while the other 91 percent were classified as "moderate"-- requiring extra monitoring of patients, immediate treatment or discontinuation of treatment, or an adjustment of the dose of the drug in question.
The most common errors involved a failure on the part of staff to anticipate expected adverse drug reactions. These included failures in looking for common adverse drug reactions and prescribing either the wrong dose or wrong drug.
The report appears in the May 23 issue of the Archives of Internal Medicine.
Although the computer system didn't resolve problems with administering medications, drug selection, dosage or monitoring, it was successful in eliminating problems reading physicians' orders, the researchers noted.
Nebeker is concerned these problems will be repeated in other hospitals. "Right now, hospitals around the world are spending billions of dollars to install similar systems with the expectation that these systems will prevent adverse drug events," he said. "Unless the computer system is designed to address the errors, the errors won't be addressed."
He believes systems need to become more sophisticated and interactive. "They have to provide direct physician decision support for ordering drugs," he said. Computer systems need to be able to tell physicians the odds of an adverse drug reaction based on patient data, as well as which drugs and doses are appropriate for which patients.
Nebeker advises caution for hospital considering the introduction of computerized medication ordering systems. "If you expect your computer system to solve all your problems, look carefully at what you're getting, and make sure you are going to get what you think you are going to get," he said.
One expert doesn't find these results surprising. "Computers are not a panacea," said Dr. Albert Wu, a professor of health policy and management at Johns Hopkins University School of Public Health. "The systems still require people to interact with them."
Wu noted that some systems do incorporate decision support, to help doctors prescribe more safely. "These programs, which make suggestions, are more likely to avert problems than dumb terminals that receive what you would have written on paper," he said.
Computerized medication order programs are worthwhile, one expert said, but they need to be tailored to avoid specific errors. "Computerized prescriber order entry is the way we should be going," said Matthew Grissinger, a medication safety analyst at the Institute for Safe Medication Practices. "But it's a computer program, and it means that you are going to have to fine tune it to make it work."
An essay in the May 18 issue of the Journal of the American Medical Association supports Nebeker's study, suggesting that before medication error and other patient safety problems can be solved, the culture of medicine needs changing.
"There has been a great deal of new awareness of the problem of patient safety," said co-author Dr. Donald M. Berwick, a professor of pediatrics and health care policy at Harvard Medical School. "But we don't see any evidence, nationwide, that there has been any shift in the current level of overall patient safety. There have been small gains but nowhere near what was called for in the report [Institute of Medicine To Err Is Human: Building a Safer Health System], or is possible."
To improve patient safety, Berwick and his colleague Dr. Lucian L. Leape, also from Harvard, believe that national goals need to be set that can be committed to and monitored.
Berwick said that improving patient safety has been seen as a technological problem. "Technology is the easy part," he said. "The hard part is changing cultures in health care."
This means changing how doctors and other health-care professionals interact. "There is an over-investment in autonomy of clinicians, even when it isn't wise," Berwick said. "There is a failure to invest in cooperation and communication."
"There is no question that if you want to make patients safer, one of the hallmarks of a safe system is high levels of cooperation, communication and teamwork," Berwick stressed.
Wu agrees with Berwick. "The biggest challenge is changing culture," he said. "Systems are not designed to be safe, they're designed to be efficient. The biggest thing that has to change is that people have to realize that safety is one of the things that we should be trying to assure."
Wu believes health-care professionals need to make patient safety a priority. "They need to understand and put into action the idea that part of their job is improving safety," he said. "Most people don't think that's part of their job description."
According to the Institute of Medicine (IOM), health care in the United States is still not as safe as it should or could be. According to the IOM's report, "at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented."
The Institute for Safe Medication Practices can tell you more about medication errors.