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Reducing Medication Errors

Apollo Hospitals, Bangalore successfully reduces its medication error rate to just 1.46 per cent. Priti Pathak tells you how

Medication error has been quite a severe problem in India for a long time but no serious measures have yet been adopted, to overcome or reduce this. However, Apollo Hospitals, Bangalore has come forward and put in an impeccable effort to eradicate this ongoing issue. This Hospital has successfully brought down the rate of medication errors to 1.46 per cent which is indeed a remarkable achievement. They were able to accomplish this task by adopting certain strategies and simultaneously keeping a balanced focus on the services/ treatment available to the patients. "Medication errors directly impact the lives of the patients and also leaves a lasting negative impression on the minds of the people about the hospital," feels Dr Umapathy Panayala, COO, Apollo Hospitals, Bangalore. It is one of the critical aspects involved in patient safety and hence was identified as one of the quality indicators for nursing and pharmacy. The instances of medication errors are potentially life-threatening and have common occurrences in hospitals. Realising this, Apollo Hospitals, Bangalore made an attempt to fight this issue head-on and improve the existing scenario of medication errors in their hospital.

Facts and Figures

The operation was started with the target of reaching three medication errors per 100 discharges within three months. The US benchmark is 5:100 and Apollo has exceeded this US standard as well with the current rate being 1.46. The medication errors were reviewed and the trend showed a further decline of medication errors by 70 per cent at the end of four months. "Medication errors are one of the nation's leading causes of death and injury. A report of US medical institutes estimates that as many as 44,000 to 98,000 people die in US hospitals each year as the result of medication errors. This means that more people die from medication errors than from motor vehicle accidents, breast cancer or AIDS," says Dr Panayala. Government agencies, purchasers of group healthcare and healthcare providers are working together to make the US health care system safer for patients and the public.

Plan, Do, Check, Act

"After identifying the loopholes, we re-designed our system of medication management" - Dr Umapathy Panayala COO, Apollo Hospitals Bangalore

The first step before getting all the forces into action was PDCA- Plan, Do, Check, Act. Through PDCA, the reasons for medication errors were analysed thoroughly. And in order to achieve this goal the following set of strategies were adopted by Apollo. "We formed the quality steering committee and the drug committee to discuss the mechanism of tracking, reporting and analysing the trends of the medication errors," discloses Dr Umesh Gupta, Director, Medical Sciences, Apollo Hospitals, Bangalore. The next step was to re-design the entire medication system. "After identifying the loopholes, we re-designed our system of medication management, right from prescribing, indenting, documenting and administering, storing, handling, labeling to reporting," adds Dr Gupta. "The staff was educated on the significance of medication errors and training sessions were conducted," shares Dr Gupta. The Hospital adopted a multi-pronged strategy with the aid of technology, to effectively reduce the error rate.

CPOE - Computerised Physician Order Entry: The doctors were authorised to indent for patient medications through the Hospital Information System (HIS). Only doctors have access to this unit. With the help of CPOE it reduced length of stay to 4.6 days. It also reduced repeat tests, turnaround times for laboratory, pharmacy and radiology requests as well as delivered cost savings. Due to the lack of CPOE systems there was a frequent occurrence of medication errors. The previous rate was six medication errors per 100 discharges which has now been reduced to 1.46 errors per 100 discharges. Thus, the effective use of CPOE has resulted not only in bringing down the rate of medication errors but has also touched on a few other aspects involved in the process of medication and treatment offered to the patient. This system saves both time and resources at the same time.

Pop-up Alerts: At the time of indenting, a pop up screen flashes when two similar sounding drugs are prescribed. "This helps in avoiding situations wherein if a doctor prescribes a particular drug, there are chances that the nurse hears something else because of the similar sound and would end up giving a wrong medicine to the patient further resulting in medication error," informs Dr Panayala. So with the help of the 'pop up alerts' system, whenever a drug ordered sounds similar to another one, an alert pops up to ask, "This is a sound alike drug, do you really want to order it?". This allows the doctor to verify the medication before indenting and thus reduces the chances of medication error.

Prescription Audit by Clinical Pharmacist: Every drug order is audited by the clinical pharmacist so as to eliminate any kind of prescription errors. Earlier there were no clinical pharmacologists at Apollo Hospitals, Bangalore but as a part of their strategy to reduce medication error, the Hospital hired clinical pharmacologists. Before ordering any prescribed medicine, the prescription is audited/ cross-checked by a clinical pharmacologist to ensure safety and avoid any kind of error in prescription. The work of a clinical pharmacist/ pharmacologist is to check for allergies, check for medication interaction, and keep a check on prescription error. They also keep a check on appropriate dosage so as to ensure that the drug matches the quantity of dose and whether it is going to the right patient.

Use of Patient Identifiers:

Again, earlier there were patient identifiers but now they have dual patient identifier systems. When the patient is admitted to the hospital, he is given a wrist band which is bar-coded and has the patient's name and the UHID (Universal Hospital Identification Device) number on it. Before dispensing the drug to their respective units, the pharmacy assistant checks if the right medication is delivered to the right patient by using patient identifiers. When the medication nurse goes to administer drugs to a patient, she would confirm identity with the patient by asking the name and checking the UHID number so that the right drug is dispensed to the right patient.

Introduction of Medication Nurse: A dedicated medication nurse is designated to each unit. Each nurse is assigned a set of patients to look after so that there is no confusion or chances that any patient remains unattended. So each patient gets personal attention and is treated with utmost care. By following such a trend it becomes easy for both the doctor and the nurse to coordinate with each other in context to the treatment given to the patient.

Introduction of Medication Trolley: The medication nurse prepares the medicines and arranges them in the medication trolley in the patient medicine cell. Due to this system, medicines are made available to patients at the right time thus avoiding delay. It also reduces any confusion that may arise while the nurse is giving medications to the patient.

'Do not disturb' Aprons for Medication Nurse: This is an apron worn by the medication nurses which read, 'do not disturb.' It is worn while administering the medicines to avoid administration errors. "The objective behind wearing such an apron during administration of medicines is to avoid any distraction and disturbance which may possibly lead to medical-error. After 15 minutes, the medication nurse visits the patient again to check for any adverse drug effects," remarks Dr Gupta.

Daily Medicine Reconciliation: The doctor reviews the drug orders on a daily basis for the correctness of the order. The ordered medicines are checked by the doctor to ensure that there is no unwanted drug that the patient would consume. Medicine reconciliation is done on a daily basis to avoid any occurrences of mishap.

Introduction of PIVA Room: A separate Peripheral Intra Venous Admixture (PIVA) unit was introduced whereby antibiotics are prepared in sterile conditions under laminar hood. Except for trained nurses wearing sterilised uniforms, even the doctors have no access to the PIVA unit.

Monthly Discussion of Medication Errors in Meetings: All the stakeholders meet every month to discuss and review trends and rates of medication errors with doctors and nurses. A report is generated on the ongoing rate of medication error and amendments are made accordingly.

Challenges in the Pathway

The first challenge was under reporting of errors by nurses and doctors which meant that accurate reports were not presented. Thus lack of authenticity is a challenge while carrying out the operation of reducing medication errors. Storage of drugs in pharmacy was yet another aspect that added to the occurrence of medication errors, as with so many brands of the same drug, it becomes difficult to find the appropriate prescribed drug. However they have made an attempt to overcome this challenge as well by encouraging doctors to prescribe the medicine by the generic/chemical name and not by the brand. This would also ease the work of the pharmacy as they would have to handle a only a few brands.

In the Indian healthcare industry medication error has not been the subject of serious examination and no major hospital is known to be systematically collecting statistics of its medication errors. Hence, this initiative of Apollo Hospitals, Bangalore is unique as it sets an example for other hospitals for researching, identifying, reporting, and reducing medication errors. The operation focused on minimising the chances of medication errors by introduction of repeat checks at each node. There is no cost as such that is involved in the process of determining medication errors, the only pre-requisites are usage of computerised systems in hospitals and optimum utilisation of available resources.

The current rate of medication errors can be sustained by using regular controls like review of data by quality steering committee, monthly meetings and process audits by quality team.

priti.pathak@expressindia.com