|Internet Journal of Medical Toxicology
A publication of The American College of Medical Toxicology
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Toxicologist and Medication Errors
Charles A. McKay MD*
Director, Medical Toxicology
Associate Professor of Emergency
University of Connecticut School of
Associate Medical Director, Connecticut Poison Control
Chair, Practice Committee, American College of Medical
Jason Vena MD
Toxicology Fellow,University of Connecticut School of
Int J Med Toxicol 2004; 7(1): 1
in medical practice occur on a daily basis in all practices and
these errors are inconsequential, representing clinically
insignificant errors in diagnosis and treatment. At times, potentially
significant errors are detected and corrected. Unfortunately, some errors
are not detected and/or corrected, and patients are harmed. Regardless of whether a
patient is harmed or not, these errors provide an opportunity for us
as practitioners to improve our systems of delivering care. The highly touted, yet often
criticized, Institute of Medicine report entitled "To Err is Human:
Building a Safer Health System" concludes that 44,000-98,000
Americans die yearly as a result of healthcare errors (1). Even with subsequent
critiques claiming true attributable deaths of only 10% this number
(2), the important messages of the IOM report should not be lost,
are usually multi-factorial and often represent problems with
errors can be prevented by focusing on system
non-punitive environment is more likely to lead to
Medical Toxicologists, we are often called upon to diagnose and
treat patients with symptoms related to medication interactions or
errors. How may we use
these cases as opportunities to investigate the causes of the
errors? Such "root
cause analyses" are a component of most hospital adverse drug
reaction reports, but these routinely suffer from incomplete
reporting. Spurred on
by reactions to the publication of the Institute of Medicine report
and others, at least 15 state legislatures have passed laws
requiring reporting of serious adverse events occurring in
hospitalized patients to their respective departments of public
health (e.g. Connecticut Public Act 02-125). Additionally, Federal
legislation has been proposed.
Although a response to the problem of preventable medical
errors is certainly appropriate, it would surely be better for the
medical profession to ensure the timely correction of our own
systems that we recognize as flawed, but have previously accepted as
Patient Safety Subcommittee of the American College of Medical
Toxicology Practice Committee is instituting a forum for Medical
Toxicologists to bring forward examples of errors and error
agreement with the editors of the Internet Journal of Medical
Toxicology, we will publish reviews on error prevention, as well as
representative cases of medical error and a systems approach to
article will serve as a framework to visualize the many steps in the
process of patient care that can lead to error. Our emphasis will be on
medication and device errors, as these represent a majority of
preventable errors (3).
Error Recognition and Reduction
cause analysis identifies common missteps in the systems that are
invoked to carry out a variety of orders. If different
physicians, nurses, or pharmacists make the same mistakes with
different medications because of a defined system problem, that
system should be changed.
If a given medication or situation is frequently associated
with errors, that particular medication or situation should be
defined as "high-risk" and safeguards built into its use.
medication error can occur at several different levels from the
prescription, transcription, dispensing, or administration of the
drug. Within each of
these processes, there is the potential for errors in the selection
of the drug or its dosage, the route and time of administration, and
the patient to whom it should be administered. These have been quoted as
the "right drug, right dose, right route, and right time for correct
Obviously, the more steps in a process, the more room there
is for mistakes. As an
example, an illegible order may be transcribed incorrectly, leading
to the dispensing of an incorrect drug or dose, which may then be
administered to the patient.
If the nurse questions the medication, this will lead to
delays in administration and a break to workflow, resulting in
problems for other patients.
If the physician responds to questions defensively or
arrogantly, the pharmacist or nurse will be dissuaded from
questioning other orders, removing a potential system check. While each of these steps
provides opportunities for system improvements, providing legible
orders with a check-back system on administration (to the original
order) would address the true cause of error. This type of analysis has
led to a number of recommendations to decrease error at this point
in the process, which may account for 1/3 of all medication errors
(written communication, Michael Cohen, Institute for Safe Medication
Practice). Some of
these rules of order writing are noted in Table 1.
number of other system responses have high yield in reducing
medication errors. Examples include reducing the reliance on memory
or vigilance by using protocols or computerized decision tools, and
improved information display (4). Standardizing and
centralizing error-prone medications or practices, such as with
intrathecal chemotherapy, and reducing the number of hand-offs,
whether it be information or people, are also
Institute for Safe Medication Practices (ISMP) has promoted a
systems approach for several decades, accumulating examples of
errors that are amenable to the corrections listed above. While education is often
touted as a method to improve care, its major role is to sensitize
providers to the common problems. Changing behavior is more
dependent on forcing functions and constraints, automation and
standardized protocols, and checklists. Some of the areas open for
improvement are listed in Table 2.
framework utilizing these concepts is based on the "Swiss cheese"
model of system incidents in Figure 1a, published by Reason (5). It emphasizes the
multi-factorial nature of errors and the concept that several
failures are necessary for such an error to reach the patient. While some errors are the
result of a single individual thwarting these processes, or an
unavoidable idiosyncratic reaction, the majority of errors are a
failure of one or more systems. Each of theses systems may
be considered a "defensive layer", whether comprising engineered
controls (alarms, etc.), human controls, or procedural/
administrative controls (5).
Applying this model to medication error yields Figure 1b; here, an error can occur only if
each layer, composed of one of the controls discussed above, is
breached (red line).
of such system failures are manifold. One such system failure can
be seen in the occurrence of benzocaine-induced methemoglobinemia
(6). Failure occurs at
the manufacturer's safeguard level with poorly-worded
instructions. A portion
of the instructions state that "Spray in excess of two seconds is
contraindicated," a separate section states that "maximum anesthesia
is produced in one minute," and therefore a healthcare
professional may easily
misinterpret the instructions as a one-minute spray. With a subsequent
administrative safeguard failure (lack of a clear procedural policy)
and a human safeguard failure (lack of awareness due to lack of
feedback from previous failures), it is understandable that topical
anesthetic-induced methemoglobinemia has been estimated to occur at
1 in 7,000 bronchoscopies (6).
Certainly, all medical toxicologists involved with poison
control centers are aware of calls from endoscopy suites regarding
this adverse medication event.
Yet how many of us have responded with specific region- or
state-wide protocols or advisory letters to prevent future
Another example of system failure occurs in the
use of methylprednisolone in two forms,
(methylprednisolone succinate) and
A 3 year-old organ transplant recipient was due to receive
140 mg of Solu-Medrol daily on an outpatient basis. The
patient had received an intravenous
dose of Depo-Medrol instead, after the nurse had double-checked
that Depo-Medrol and Solu-Medrol were both
This error was detected by the patient's mother only upon
administration of the next day's dose, when she noticed that the
correct formulation was "clear" while the previous (erroneous) dose
had been "cloudy."
While the child did not suffer an untoward event, failures in
the system had to occur at multiple system safeguards: education,
labeling (the warning against IV use of the depot form is in small
print, Figure 2), and dispensing at the pharmacy
and the bedside (7).
Educational Effort Towards Medication Error
the framework of Figure 1b, we encourage ACMT members to
submit case vignettes to the Internet Journal of Medical Toxicology
(IJMT) that demonstrate these problems. These vignettes can be in
the form of a short paragraph, with graphics provided for
transcription errors, look-alike or sound-alike medications. The ideal submission would
include a proposal of how this problem is or can be prevented from
occurring again. It
should be remembered that technology itself can introduce new
sources of error (8). Reports of newly introduced sources of error
from correction attempts would also be welcomed. Lack of knowledge
and familiarity are often cited as proximate causes to preventable
medication errors (9).
Therefore, we encourage ACMT members to use these examples in
their own educational efforts and review these system issues for
adaptation to their own practices or institutions. We also thank
those authors who have previously submitted manuscripts that have
addressed patient safety and medication error issues. Links to these
manuscripts are provided after the references.
Kohn LT, Corrigan JM,
Donaldson M. To Err Is Human: Building a Safer Health System.
Washington, DC: Institute of Medicine; 1999.
McDonald CJ, Weiner M,
Hui SL. Deaths due to medical errors are exaggerated in Institute of
Medicine report. JAMA 2000; 284(1): 93-5.
Leape LL. Error in
medicine. JAMA 1994;272(23):1851-7.
Bates DW, Gawande AA. Improving safety with
information technology. NEJM
Reason J. Human Error: models and
Institute for Safe
Medical Practice. Benzocaine-containing topical sprays and
October 3, 2002. (last accessed September,
Institute for Safe
Medical Practice. Mind your "Medrols". http://www.ismp.org/MSAarticles/sprays.htm,
May 29, 2003. (last accessed September, 2003)
Kinnaird D, Wilson JP.
Prescription errors occur despite computerized prescriber
order entry. American Journal of Health-System Pharmacy
Leape LL, Bates DW,
Cullen DJ, et al: Systems analysis of adverse drug events. JAMA
- Becker C. Scanning for higher profits. The FDA's plan to require bar codes on commonly used medical products will do more than improve patient safety. Modern Healthcare 2003;33(24):6-7,16.
- Bizovi KE, Beckley BE, et al. The effect of computer-assisted prescription writing on emergency department prescription errors. Acad Emerg Med 2002; 9(11):1168-75.
- Cucchiara B, Messe S, Kasner SE. Danger of treatment protocols. Stroke 2003;34(5):E19.
- Freedman JE, Becker RC et al. American Heart Association. Council on Clinical Cardiology Subcommittee on Acute Cardiac Care, Council on Cardiopulmonary and Critical Care, Council on Cardiovascular Nursing, and Council on Stroke. Medication errors in acute cardiac care: An American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Acute Cardiac Care, Council on Cardiopulmonary and Critical Care, Council on Cardiovascular Nursing, and Council on Stroke. Circ 2002;106(20):2623-9.
- Freund PR, Posner KL. Sustained increases in productivity with maintenance of quality in an academic anesthesia practice. Anesth Analg 2003; 96(4):1104-8.
- Gandhi TK, Weingart SN, et al. Adverse drug events in ambulatory care. NEJM 2003;348(16):1556-64.
- Kaushal R. Shojania KG. Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Int Med 2003;163(12):1409-16.
- Kozer E, Scolnik D et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics 2002;110(4):737-42.
- Lesar T, Mattis A, et al. VHA New England Medication Error Prevention Initiative Collaborative. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Joint Commission Journal on Quality & Safety 2003;29(5):211-26.
- Meadows M. Strategies to reduce medication errors. How the FDA is working to improve medication safety and what you can do to help. FDA Consumer 2003;37(3):20-7.
- Morrissey J. Encyclopedia of errors. Growing database of medication errors allows hospitals to compare their track records with facilities nationwide in a nonpunitive setting. Modern Healthcare 2003;33(12):40, 42.
- Peth HA Jr. Medication errors in the emergency department: a systems approach to minimizing risk. Emerg Med Clin North Amer 2003;21(1):141-58.
- Seifert SA, Jacobitz K. Pharmacy prescription dispensing errors reported to a regional poison control center. J Tox - Clin Tox 2002;40(7):919-23.
- Sherman FT. Older patients and the aging Columbia shuttle. Examining organizational accidents to prevent disastrous outcomes. Geriatrics 2003;58(3):13-4.
- Tierney WM. Adverse outpatient drug events--a problem and an opportunity. NEJM 2003;348(16):1587-9.
- Tranum D, Grasha AF. Susceptibility to illusions and cognitive style: implications for pharmacy dispensing. Perceptual & Motor Skills 2002; 95(3 Pt 2):1063-86.
We would like to thank our colleagues who
have contributed previous articles to IJMT with regard to general
issues of medication and patient safety,
Joshua G. Schier, MD
Lewis S. Nelson, MD
S. Hoffman, MD
Acetaminophen Dosing Error in A Child
Med Toxicol 2003; 6(2): 7
Heather Long, MD
Lewis S. Nelson
MD, FACMT, FACEP
Robert S. Hoffman, MD
Medication Error Resulting in Death
Med Toxicol 2003; 6(1): 2
Howard Greller, MD
Lewis S. Nelson MD,
Physician-Patient Miscommunication Results
in Medication Error
Med Toxicol 2003; 6(1): 3
Baum, M.D., FACMT
Dispensing Error: Calcium-Channel Blocker
Substituted for Neuroleptic
Med Toxicol 2001; 4(4): 26
American College of Medical
Errors and Adverse Drug Reactions or Events (Position
Int J Med Toxicol 2001; 4(3): 23
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