Miscommunication of drug orders

This article was published in The West End Times October 29, 2011.

Medication errors are said to affect at least 1.5 million Canadians per year. According to the Canadian Institute for Health Information, one in 10 patients receives the wrong medication or the wrong dose while in hospital. The Canadian Institute for Health Information’s fifth annual report (Health Care in Canada 2004) used the institute’s studies and Statistics Canada data to examine patient safety. For the first time, it compared how common some errors are. Nearly a quarter of Canadian adults say they or a family member have experienced a preventable medical error. Drug errors and infections top the list.

It is estimated that the number of lives lost to mistakes that could have been avoided with medication error prevention techniques alone represents approximately 7,000 deaths annually, and medication errors occur in just about one out of every five doses given in hospitals. These are voluntary reports and we know that many errors may go unreported, so the number of medication errors that actually occur is thought to be much higher.

Because the practice of medicine is so complex, there are many opportunities for mistakes to occur at any step between diagnosis, transcription, prescription and administration of the medicine. Some of the most common causes of medication errors include:

• disorganized work flow
• fatigued staff
• frequent interruptions and distractions
• emphasis on volume over service quality
• stress
• ineffective communication with patients
• A pattern of inadequate staffing.
• Miscommunication of drug orders; which can involve messy handwriting, incorrect abbreviations, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units;
• Knowledge deficits due to improper training or education;
• Unavailable drug information (such as lack of up-to-date warnings)
• Lack of appropriate labeling as a drug is prepared and repackaged into smaller units. And the list goes on and on….

Although many would like to put the blame on a particular individual for medication errors, I prefer to blame the system and the fact that we do not find a “Better Way.” How about counseling patients about their medications and showing the pills to the patient to be sure they are what they expect? The problem is that there is very little teaching going on. Nurses spend so much time dispensing medications while that time could be better spent educating the patients to self medicate safely. Too often patients are sent home with no knowledge about their medications only to be told that they are non-compliant and to blame for their poor health. Just take your pills!!!

Years ago when I worked in hospitals I proposed that we teach patients about their medications and the reason for taking them. Once it is determined that they understand what they are taking, for what reason and the possible side effects, their medication could be locked in their bedside tables for self administration. As soon as we place patients in hospital beds we think they are no longer capable of looking after themselves. What a waste of nurses’ time and what a loss of learning opportunities for patients.

After 15 years working in home care I am shocked that little has changed. I am even more convinced that hospitals should be for a diagnosis and immediate treatment needs and there should be a real push for early discharges to home. With support, monitoring and teaching about their care needs including medication follow-up, people can do very well and stay out of hospitals. And yes…….we now have the technology to monitor and teach remotely at a fraction of the cost to the health care system. Let’s put people in charge and give them the necessary tools to do so.

I enjoy getting calls and feedback. Thanks for your calls and messages. If you leave your number, I will get back to you. I am looking for five people who would like to try our free monitoring from the comfort of their home. For more information contact me at Health Access Home and Nursing Care 514-695-3131, donna@ashcanada.com. www.ashcanada.com