Automated System to Prevent Medication Errors

The Journal of the American Medical Informatics Association has published a new study by researchers at the Cincinnati Children’s Hospital Medical Center (CCHMC) where they designed and tested an automatic system to detect medication administration errors (MAEs). A medication administration error is a discrepancy between the medication the prescriber intended and what the patient receives.

In reviewing 91 studies, the researchers estimated that 20 percent of hospital errors were MAEs. MAEs have the potential to cause real patient harm and occur often in health care settings despite the advent of new technologies, such as electronic health records (EHR) and smart infusion pumps. Most of the existing MAE detection systems send out frequent alerts to physicians that result in what is known as “alarm fatigue.” Overwhelmed by the number of alerts they receive, physician responses to serious concerns may not be immediate.

The system developed for CCHMC was designed to identify MAEs in real time. Over the four months of the study, the automated system detected MAEs with a sensitivity rate of 85.3 percent, whereas the practices in place had a sensitivity detection rate of 4.3 percent. The total number of medication administrations during that time was 10,104 and 116 MAEs were identified by physicians.

Of these MAEs:

• Seventy two percent were clinical errors that would affect the patient negatively. The automated system was able to identify 86.7 percent of these clinical errors.
• Substantial overdoses or underdoses of medication accounted for 13 percent of the 116 MAEs. These were identified by the automated system 100 percent of the time.

In the study, the automated system was shown to have a positive predictive value of 78 percent. Duration of patient exposure to potential harm could likely decrease from 256 minutes to 35 minutes with use of the system.

Combating Alarm Fatigue

Many health care facilities have systems in place for medication error detection, however, some have low positive predictive values, while others are too resource intensive, and alarm fatigue is an issue for physicians as mentioned above. One study found that health care providers received an average of 76.9 electronic health record notifications every day, with only 15.5 relating to patient test results. An estimated 66.8 minutes was needed daily to deal with EHR notifications.

By contrast, the system in the CCHMC study generated roughly one medication error notification per day during four months for all medications in aggregate. This suggests that with relatively little additional work for the staff, a significant safety benefit could be achieved reducing the risk of hospital malpractice.

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Medical errors happen in just a moment but can have a devastating impact on a person’s life. Contact an experienced New Jersey medical malpractice lawyer at Eichen Crutchlow Zaslow, LLP if you believe that you or a loved one has experienced negligent medical care. Call 732-777-0100 today to schedule your free consultation or complete our online contact form. We have convenient locations in Edison, Toms River, and Red Bank, New Jersey to serve you.