E-prescribing urged as one strategy to prevent medication errors

A panel's report calls on all physicians to prescribe electronically by 2010, but experts say that's a reach.

By Kevin B. O’Reilly — Posted Aug. 21, 2006

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At least 1.5 million people are injured annually by preventable medication errors that occur at every stage of the process, from prescribing to dispensing to patient administration, according to a July Institute of Medicine report.

The new report says physicians, nurses, pharmacists, patients and drugmakers must work together to combat the many factors that contribute to the persistence of these errors, which the IOM earlier reported kill an estimated 7,000 people a year.

"The 1999 report ["To Err is Human"] raised awareness about errors in general," said J. Lyle Bootman, PhD, ScD, co-chair of the IOM Committee on Identifying and Preventing Medication Errors and dean of the University of Arizona College of Pharmacy. "The current report makes clear that we still have a long way to go."

Albert W. Wu, MD, MPH, a panel member and professor of health policy and management and internal medicine at Johns Hopkins University in Baltimore, said the report's findings make clear that medication errors are the most far-reaching of medical errors.

"I'm a patient-safety researcher, and even as we went through the process I was surprised by just how common and how serious a problem this is," Dr. Wu said. "We all need to wake up and take a part in fixing it."

Most important for physicians, the panel called on all prescribers to have a plan to implement an electronic prescribing system by 2008 and to have such systems in place by 2010.

Wilson D. Pace, MD, a panel member and Green-Edelman Chair for Practice-based Research at the University of Colorado, said even the most talented physicians need electronic systems to help them prescribe safely.

"With 15,000 medications available, it's virtually impossible to track all of those anymore just using your memory," Dr. Pace said. "Electronic prescribing is one of the keystones of all of this. ... It allows us to apply decision support, capture medication lists and transfer information."

The electronic prescribing recommendation is critical, said Frances Griffin, an Institute for Healthcare Improvement project director.

E-prescribing "will reduce certain types of errors, especially those related to handwriting," Griffin said. "But it's going to be a challenging recommendation to implement, because it's very expensive technology."

While most observers agree that e-prescribing systems could greatly reduce medication errors, many called IOM's timeline premature.

"I'd call that a reach goal," said Anthony J. Schueth, managing partner of Point-of-Care Partners LLC, a health care information technology consulting firm based in Coral Springs, Fla. While a quarter of office-based physicians have electronic medical record systems, he said, only 13% are prescribing electronically.

"You've got to go out and recruit doctors and convince them that they should use these systems, install and train them, and figure out who's going to pay," Schueth said.

Increasing adoption among physicians by 10% a year is a more reasonable target, he said. It's the mark that the Centers for Medicare & Medicaid Services laid out in a notice of proposed rule-making last November. CMS and the Agency for Healthcare Research and Quality have funded five pilot projects, including one for which Schueth acts as project lead, to test foundational electronic prescribing interoperability standards, which have been a barrier to widespread adoption. CMS also is funding pay-for-performance demonstration projects that incorporate e-prescribing.

AMA Board Chair Cecil B. Wilson, MD, said it will be a while before most -- not to mention all -- physicians can prescribe electronically.

"The marketplace for health information technology in the physician office is still very much in its infancy," Dr. Wilson said in a statement. "Physicians face a dizzying array of choices when trying to purchase [health IT], while struggling with high costs, interoperability and ease of use."

He said there's much more work to be done before the majority of physicians can e-prescribe in a comprehensive way that includes safety and security capabilities.

Experts believe the cost savings once electronic systems are up and running will be significant.

In 2004, the Center for Information Technology Leadership estimated that e-prescribing could save $29 billion annually thanks especially to systems that automatically alert physicians to formulary coverage and generic drug options.

"When you look at the studies that have been done -- and there are physicians who do -- it appears that the greatest portion of the savings accrues to payers, who aren't being asked directly to pay for the service," Schueth said. "Physicians are saying, 'Can't you pitch in?' "

The costs for physicians to implement systems are also significant, and financial assistance to help offset the initial costs has been limited.

According to information accompanying the CMS final rule on e-prescribing standards, license fees can range from $80 to $400 per physician per month.

The IOM's report calls for $100 million for research on preventable medication errors, but it doesn't advocate any direct funding to help physicians pay for e-prescribing systems.

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Medication errors add up

The toll of preventable medication errors is uncertain, but in a July report, an Institute of Medicine panel estimates that at least 1.5 million people are harmed annually by preventable medication errors. Here's a breakdown of these estimates:

400,000 preventable drug-related injuries occur each year in hospitals. It costs an extra $3.5 billion to treat those injuries.

800,000 preventable drug-related injuries occur in long-term care settings.

530,000 preventable drug-related injuries occur among Medicare recipients in outpatient clinics. In 2000, it cost $887 million to treat those injuries.

25% of all medication errors are due to similar drug names.

33% of drug errors, including 30% of deaths, are due to poor labeling and packaging.

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What you can do to reduce errors

A July Institute of Medicine report says office-based physicians should take these steps to minimize medication errors:

  • Put an electronic prescribing plan in place by 2008; implement e-prescribing by 2010.
  • Reconcile medications at transition points -- admission, discharge and transfer.
  • Create a routine to reconcile medication changes with the pharmacy record.
  • Keep an accurate medication list for each patient, including over-the-counter and complementary and alternative medications. Ask patients to bring their medications in periodically to keep the list up to date.
  • Do the following when prescribing new medication: Ask about allergies, inform the patient of indications for all medications, explain common or significant side effects, consult electronic or other reference sources for questions, avoid abbreviations and include patient age and weight when applicable.
  • Ask regularly whether patients are taking their medications, including as-needed drugs. If they aren't taking the medication, it may signal that a patient had an adverse reaction to the drug.
  • Monitor the patient for response to medication therapy and ask regularly about side effects or adverse drug events.
  • Standardize communication about prescriptions within the practice; standardize and improve handoffs to the primary pharmacist.
  • Ask the primary pharmacy about the patient's refill history.
  • Work as a team with the primary pharmacist and nurses.
  • Minimize the use of free samples; when dispensing free samples, apply standards similar to those a pharmacy would use.
  • Exercise particular caution in high-risk situations, such as times when a physician is stressed, sleep-deprived, angry or is supervising inexperienced personnel.
  • Report errors and adverse drug events to the Medication Errors Reporting Program, jointly run by U.S. Pharmacopeia and the Institute for Safe Medication Practices as well as the appropriate patient-safety organization or authority, depending on the state.

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