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Take one physician’s barely legible handwritten prescription, add a medication with a name that looks and sounds just like another, stir in a nursing shortage and what do you get? A recipe for disaster, according to the 1999 Institute of Medicine report, one that has had a real effect on how hospitals do business. The IOM report, the most comprehensive ever done on the subject, estimated that between 44,000 and 98,000 people die in U.S. hospitals each year from medical mistakes—more than deaths from breast cancer, AIDS or highway accidents.

More than anything, the IOM report removed the cloak of secrecy and denial historically associated with the subject of medical errors. Today, few argue about the extent of the problem, although the Joint Commission on the Accreditation of Healthcare Organizations has collected only 1,199 errors since 1995. That reason is obvious, said Ann E.J. Kobs, president of Type 1 Solutions, a company in Cape Coral, Fla., that promotes medical standards of review for hospitals and medical centers.

"The Joint Commission’s primary reason for going to voluntary reporting is that we in health care have to absolutely find out what’s breaking down and how to fix it," said Kobs, a former associate director of the Joint Commission. But there is so much fear that if the Joint Commission gets involved, then "it’s no longer covered under peer review, patient safety, and therefore we’ll be sued."

"We’re not looking for the bad apple, we’re looking for system improvement," said Ginger Malone, MSN, RN, leader of care innovation at Children’s Hospitals and Clinics in Minneapolis. "Whenever we talk about patient safety, we talk about the holes in the system. We don’t ask who did it, we ask what happened. We don’t use the word error very often; we talk about accidents. We don’t talk about an investigation, we talk about analysis. So we’ve been pretty methodical about how we can shape the culture with the language."

Where once an incident report would have required a physician or nurse to check off a series of little boxes to specific questions, Children’s Hospital now asks for narrative reporting. The change has helped create an atmosphere of openness that was featured in a U.S. News & World Report cover story last year.

"It’s also created a web of stories within the hospital; there are more stories than we know what to do with," Malone said. "The near misses, the good catches, they create safety every day. A physician who walks into a meeting says, ‘Oh, I just ordered this med and the pharmacist called me and caught me!’ "

Common mistakes
Because medication errors rank among the most common mistakes—one study found that one in every four medications dispensed in several large, unidentified hospitals involved some degree of error—they’ve grabbed a lot of the attention.

"That’s because there are so many steps to the process of medication," said Nancy Davis, MA, MN, RN, chief nurse executive of Ochsner Foundation Hospital in New Orleans. "The physician writes the prescription and he or she is in a horrible rush, their handwriting is beyond words bad, and then the copy the pharmacy gets is a very faded version. So the potential for errors is huge. And once it’s dispensed, it shows up at the nursing station, where the nurses may be distracted."

Many administrators say that bar coding soon will be mandatory around the country. The Leapfrog Group, a patient safety consortium created by corporate leaders, is calling for a system of computer physician order entry (POE) that will eliminate medical errors caused by poor handwriting.

By 2002, Davis said, all nurses at Ochsner will be given laptop computers with which they will be required to bar code their badges, the wristbands of patients and prescribed medications. The system has been equipped with both the potential for tracking medication errors and alerting staff members to potential mistakes.

In June, the Joint Commission issued a sentinel event alert on look-alike, sound-alike drug names. It’s a constant problem, but one, presumably, that the POE can address.

"I just got a letter from a pharmaceutical company telling me to watch the spelling of an anti-seizure medication that depresses brain function, called lamictal, because it’s spelled almost exactly like a toe fungus medication called lamisil," said Ted Eytan, MD, lead physician in the division of medical informatics for Group Health Cooperative in Seattle.

Group Health recently installed a POE that physicians will have to log into before prescribing. "The system will immediately respond and say, ‘Wait a minute, you’re a psychiatrist; you shouldn’t be prescribing a chemotherapy agent.’ "

Health care advocates are cautious when it comes to the computer’s fix-it role. "The high-tech approach is important," said Joanne Turnbull, executive director of the National Patient Safety Foundation, "but we’re worried about it because it doesn’t address the professional interactions.

"We have good doctors and nurses out there, and they’re set up to make mistakes because the system doesn’t support their work. It’s because the processes are from the 1950s. There’s no team-based training, no collaboration."

Nurse/physician communication is one of the most critical aspects of patient safety. Informal communication can be especially troublesome: A physician passes a nurse in the hall and says, "Oh, by the way, give this medication right now to Sally in Room 6." Many hospitals now are seeking to eliminate all verbal orders.

"It’s because there’s so much room for an accident," Malone said. "It’s usually a high-stress situation. We’re often distracted or fatigued, and there have been some major accidents around the country where a nurse has given some medication.

"We have to be intentional about our communication. We have to be very open and share information. We’ve discovered that when a doctor is not open, and is highly conflicting and derogatory, nurses will actually withhold information—and that will ultimately be a safety issue for the patient."

In other words, the real changes will never be made without making changes in nurse/physician communication and relationships.

Kobs couldn’t agree more. "One of the things we can learn from the engineering industry is building safety into our practices," she said. "Yet when you speak to physicians, they arch their backs a little bit and say, ‘You’re not going to tell me how to practice medicine.’ But if a nurse complains about a doctor, the doctor goes to administration and nine times out of 10, that administration backs the doctor."

That is starting to change, though. A new policy at Children’s Hospital stipulates that nurses who "stop the line" by intervening or halting a physician’s order—if they consider that order unwise or unsafe—cannot be disciplined. Hospital administrators meet regularly with nurses to teach them how to stand up to physicians.

After a series of articles last year in the Chicago Tribune called widespread attention to the subject ("Nursing Mistakes Kill/Injure Thousands," one headline read), the governor of Illinois appointed a task force. Hundreds of health professionals and consumers applied to serve, and the group issued its final report in April. Among other issues, it advised the creation of a center for patient safety, staffing recommendations and a standardized system for medical error reporting.

Unfortunately, said Ann O’Sullivan, MSN, RN, president of the Illinois Nurses Association, the task force’s efforts elicited no legislative changes.

"The reason why, according to my perspective, is that you could not get agreement among all the parties, especially on [nurse] staffing," said O’Sullivan, also a member of the task force. "The INA introduced a bill this year on safe staffing, which the hospital association opposed." The Illinois Hospital & HealthSystems Association argued that its members already follow staffing standards and don’t need additional legislation and regulation.

Like so many changes that have occurred in medicine, the change may well come from the pediatric side, where the margin for error—especially when it comes to medication—is so narrow. Consider, for example, as a recent article in the Journal of the American Medical Association pointed out, that the rate of error is three to six times higher on a pediatric unit than an adult unit.

"There are some things we’ve learned about patient safety and they have to do with team partnership, that whole notion of ‘nothing about me without me’," Malone said. "In pediatrics, it means that any member of the team shouldn’t proceed down a plan or diagnosis or treatment without fully engaging the parents and children. Because the parents know so much more about the child than we could ever presume to know."

It happens often, she said, that parents will identify a potential error. "A nurse brings a medication into the child’s hospital room, and the mother may say, ‘I don’t remember her getting that,’ or ‘Is that the right dosage?’ "

In the past, a nurse or pediatrician at Children’s Hospitals probably would have responded by glossing over the parent’s concern, but these days it’s considered "a huge red flag," Malone said. Now, staff also are trained to disclose all near misses to family members.

"That approach ultimately builds trust, rather than eradicating it. Families have told us, ‘We know things happen. We’re all human and mistakes occur. It’s about the system and the processes. We know the nurses and physicians and staff at Children’s aren’t intending to do harm.’ If we tell them the truth and disclose to them what’s happened, they’ll trust Children’s more. Because what families have said to us, even when there’s been a death, is, ‘We want to make sure it never happens again.’ "