Hospitals have switched from handwritten prescriptions and pills in Dixie cups to computerized order entry and robotic drug dispensing, but one thing hasn't changed over the past two decades: the small but severe risk of injuries and deaths from medication errors.
In a new report, Minnesota hospitals disclosed four deaths and 10 serious injuries related to medication errors in the 12-month period ending last Oct. 6. That's the highest total in 12 years of "adverse event" reporting in Minnesota, which remains one of only five states to publicly disclose hospital errors as part of a concerted effort to prevent them.
"One is too many," said Dr. Beth Thomas, interim chief medical officer for Fairview Health Services, which reported five medication errors at the University of Minnesota Medical Center last year and a sixth at Southdale Hospital in Edina.
Disabling or fatal medication errors have vexed hospital officials statewide, because they can occur at so many different points along the prescription pipeline.
Among the other 28 errors tracked by the Minnesota Department of Health, some have been easier to define. Hospitals, for example, had fewer incidents in which objects were left inside surgery patients, because their collaborative reporting identified lab sponges and device fragments as culprits. Only 22 such cases occurred last year, compared with 37 in 2011.
In all, last year's report included 316 adverse events, a slight increase from 308 in 2014, according to the new report. Fatal patient falls declined from 79 in 2014 to 67 last year, but losses of irreplaceable biological specimens increased from 20 to 27.
Patterns emerging
Among medication errors, one occurred when a drug was given by a shot rather than intravenous pump. Another involved a prescription added after a patient had already received a take-home drug list. Another involved a medication that was halted before surgery but not restarted.
"There are many transition points" in prescribing, said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association. "The medication is ordered by the physician, so there is room for human error there. The medication is then checked off by the nurse … and then evaluated by the pharmacist."