Electronic Medication Transactions: The quest to eliminate error

Neesha Patel

Medical error is defined as commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences. This could mean that the healthcare provider chose an inappropriate method of care, such as giving a patient a certain asthma drug without knowing that he or she was allergic to it or chose the right course of action but carried it out incorrectly, such as intending to infuse a patient with diluted potassium chloride (a supplement), but inadvertently giving the patient a concentrated, lethal dose.

A study carried out by the Institute of Medicine (IOM) concluded that in the US, more people die in a given year as a result of medical error than from motor vehicle accidents, breast cancer or AIDS. However, such numbers do not tell the whole story-people in the hospital are just a small proportion of those at risk. Doctor's offices, clinics, and outpatient surgical centres treat thousands of patients a day; retail pharmacies fill countless prescriptions; and nursing homes and other institutional settings serve vulnerable patient populations. "These stunningly high rates of medical errors-resulting in deaths, permanent disability and unnecessary suffering are simply unacceptable in a medical system that promises to do no harm," states William Richardson, CEO of WK Kellogg Foundation, Michigan.

Medication errors

Recent reports have shown that medication errors are among the most widespread; even the seemingly simple process of giving patient medicine; the right drug, in the right dose, to the right patient, at the right time is, in reality, teeming with opportunities for error such as stocking of full-strength drugs in hospitals that may be toxic if not diluted, to improper administering of medicines that results from illegible writing in a patient's medical records.

In addition, when several practitioners treat a patient, they often do not have complete information about the medicines prescribed or the patient's illness. The IOM estimates that preventable medication errors result in more than 7,000 deaths each year in hospitals alone and 10,000 more in outpatient facilities.

"Name confusion is one of the most common causes of drug-related errors," says Peter Honig, an FDA expert on drug risk-assessment. In one case, a physician wrote a prescription for "Celexa 200mg." Since the drug is available only in 20 and 40mg doses, the doctor was called and he corrected his prescription to the intended "Celebrex 200mg."

Another glaring example is about two women getting poisonous doses of chemotherapy while being treated for recurrent breast cancer at the prestigious Dana-Faber Cancer Institute in Boston. Betsy Lehman, age 39 at the time, died as a result of the error, and the second patient suffered permanent heart damage and died from cancer several months later. Instead of prescribing the anti-cancer drug cyclophosphamide to be given on each of the four days as planned, the doctor ordered the drug's combined four-day dose so that the total was given to the patients each day.

Need for electronic medication transactions

The fatal miscommunication at the Dana-Faber Cancer Institute prompted the institute to install a USD 1.7 million computer system-doctors don't hand write prescriptions anymore, but instead fill out an electronic form with the patients personal information, as well as the name of the drug, the dose, and the number of days the medicine is to be given. The information goes into the computer system, which compares the information with upper dose limits for the drug and pre-programmed guidelines. If the doctor seems to have made a mistake, the computer signals the error.

In 1999, New York legislation permitted doctors to email their prescriptions to pharmacies in addition to allowing pharmacists access to online medication profiles, as long as patients authorise the sharing of their records. The new regulation required that all prescription and medical data be encrypted when sent over the World Wide Web to prevent unauthorized access to patient information, and any pharmacist that accessed the electronic database for any reason other than filling a prescription could lose their license and possibly be subject to prosecution. The state Board of Regents made the decision to clear the way for online drug transactions as an effort to reduce the number of adverse drug reactions and prescription errors caused by unclear handwriting or phone orders.

This system would also avoid confusion when patients use different pharmacies for different prescriptions and end up with unsafe drug interactions. Since such legislation, several internet ventures like PlanetRx and Drugstore.com and Merck-Medco Managed have begun to replace trips to the local pharmacy with prescription refill orders.

The explosion in mobile medical technology improves both the quality of a doctor's professional work as well as their efficiency in handling administrative overheads; when integrated with the healthcare enterprise IT infrastructure, support medical professionals by enabling them to think through complex decision making processes. It enables doctors to refer to vast stores of relevant information that are critical to decision making at the point-of-care, make informed decisions and act on them by conducting transactions right from the device.

Indian Scenario

Medical error has not been the subject of serious examination in India and no major hospital is known to be systematically collecting statistics of its medical errors. Dr NS Dixit, a noted heart specialist, is critical of the way medicines are dispensed and states that most medication errors in India occur because of illegible prescriptions; 'Incidal' the anti-allergy drug can be read as 'Indiral', a beta-blocker. The latter of which can produce strong reactions in asthmatic patients. Error checking becomes more difficult to trace as chemists avoid giving a bill listing the medicines, pharmacies often dispense medicines in the physical absence of a trained pharmacist and prescription drugs are routinely dispensed without insisting on a prescription.

While technology may not be the perfect solution for the Indian price sensitive market, it holds great promise for researching, identifying, reporting, and reducing medication errors. In particular, electronic medication transactions with proper systems design, implementation, and maintenance can contribute significantly to the prevention of medication errors. As of now, more research is required into the epidemiology of medication errors, with the hope that various reduction initiatives will gain strength from the recent surge of public interest. In the words of nineteenth-century essayist William Channing, "error is defined as the discipline through which we advance."