In 2006, The Institute of Medicine issued a shocking report on the prevalence of medication errors in the United States. A medication error involves any breakdown or failure, either from prescription of a medication or the medication being used or administered properly (Wu, 2006). They can include improper prescribing, ordering, dispensing, administering, and drug monitoring after administration. Errors can also occur when a patient does not take a medication as directed (Wu, 2006).
The report found at least 1.5 million Americans are injured every year by medication errors (Wu, 2006). Wu (2006) stated that on average, “every hospital patient is probably subjected to at least one medication error every day.” While most do not cause harm, at least 7000 people die every year and over $3 billion dollars annually goes toward treating the consequences of these errors (Wu, 2006). The report made recommendations to reduce these occurrences, one of the most important being that physicians use electronic information resources and electronic decision-making aids built into a computer which would have data on the patient, their medications and allergies, and could prevent improper prescribing in addition to catching errors before the medication reaches the patient (Wu, 2006).
Classen et al. (2020) researched the safety records and performance of electronic health record systems (EHRs) in the United States from 2009 to 2018, while also evaluating hospitals that used the National Quality Forum Health IT Safety Measure during the same timeframe. This computerized EHR safety test used simulated medication orders that have previously either injured or killed patients, to evaluate how well each hospital’s EHRs could identify potential medication errors. The study found that “despite the broad adoption of electronic health record (EHR) systems across the continuum of care, safety problems persist.” (Classen et al., 2020) The EHRs were found to meet the most basic safety standards less than 70% of the time, and the systems only showed modestly increasing scores over the ten-year study period (Classen et al., 2020).
The goal of publishing this study is to ensure EHRs are continuously improved upon for safety purposes, and as a result, decrease medication errors. The Food and Drug Administration (FDA) has made recommendations to help reduce medication errors unrelated to EHRs. When new medications are approved for marketing, the names must not be similar to existing medications, and the branding must meet requirements making it easily readable so as not to be confused with other medications or dosages (FDA, 2019). The FDA (2019) also implemented rules requiring barcodes to be placed on all packaging so that healthcare professionals can scan the medication and the wristband of the patient to guarantee the right medication, dose, and route of administration are given to the correct patient.
Since the 2020 published study written by Classen et al., it is evident that improvements need to be made to EHRs within all hospitals across the United States. It was assumed that when implementing the EHRs, the medication errors would markedly decrease, but this was not the case over the last decade. Hospital EHRs are missing up to one third of dangerous drug interactions and other errors in medication administration (Classen et al., 2020). Classen stated in an interview that “you would never get on an airplane if an airline could only promise it could get you to your destination safely two-thirds of the time.” A patient does not always have a choice when being hospitalized, and it is of the utmost importance for their safety to make changes to EHRs and medication administration protocols so that medication errors are decreased.
Classen DC, Holmgren AJ, Co Z, et al. National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018. JAMA. 2020;3(5): e205547. doi:10.1001/jamanetworkopen.2020.5547
Dunleavy, B. (2020, May 29). 33% of drug errors missed by electronic health records systems. Retrieved from https://www.upi.com/Health_News/2020/05/29/33-of-drug-errors-missed-by-electronic-health-records-systems/7911590758184/?ur3=1
FDA. (2019). Working to Reduce Medication Errors. Retrieved from https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors
Wu, A. (2006, August 3). Q&A: Medication Errors in the United States [Interview by T. Parsons]. Retrieved from https://www.jhsph.edu/news/stories/2006/wu-medication-errors.html