Keeping the Rx train on track

The medication use system is hooked together, kind of like cars on a train. And the cars would be labeled:

• prescribing


• dispensing


• administering


• monitoring
  

Seminal medication error literature suggests that errors originating in the prescribing car account for about 40% of all errors and represent 28% of harm-causing errors. Nearly 1/2 of errors that arise during prescribing are picked up before they reach a consumer, mostly because the cars that follow contain check points and feedback loops to detect and right the error. But this means that a substantial number of errors remain undetected, errors that potentially harm patients, or in some way derail the intended plan of care.

Computerized Prescriber Order Entry (CPOE) holds the promise of increasing the reliability of activities that occur in the prescribing car. Automation ensures that patient allergies, duplication of therapy, and potential drug interactions are considered during each prescribing cycle in a way that reliance on even the most diligent human cannot.

When CPOE's best potential is realized, active errors originating in the prescribing phase will be reduced. So will passive errors that occur when high-stakes drug information is not transmitted across the continuum of care and is not readily available to treating clinicians.

Depending on the outcome of national discussions surrounding the use, the meaningful use, of 20 billion health IT-earmarked dollars, the average Walmart shopper can expect to see universal e-prescribing, ummm, soon. Until e-prescribing is fully implemented, people in the U.S. will live (or not, as the case may be) with hybrid systems.

Here's what I tell consumers to do to decrease the chance that a prescribing error will make it home:

1. When you receive a prescription for a medicine, it should be legible. Ideally, this means that the prescription is sent to your pharmacy electronically and you receive a printed copy. If it's not an electronic system, and you have to hand-carry a prescription to the pharmacy, it should be legible.

A "legible" handwritten copy of a prescription is one you can read. (It's not necessary for you to understand every word, term, or symbol, but you should be able to see and distinguish each word and number clearly). Pharmacists and pharmacy technicians have a lot of specialized knowledge, especially about drug names and products that are currently on the market. But they don't receive CIA-level training to decode poor penmanship. Making "an educated guess" is not what they're supposed to do nor is it what you want them to do. (Think of your prescription like the directions a pilot receives. Would you be willing to taxi to a runway knowing the pilot received directions he couldn't read clearly?)

2. Know what's included on your prescription and why it's important:

• who is prescribing it


• who it is being prescribed for


• the date of birth of the patient (or another identifier in addition to the patient's name)


• known drug & food allergies of the patient


• the name of the drug


• the dose of the drug


• how many pills or how much liquid should be taken in order to achieve the desired dose


• how often the drug should be taken (usually expressed in "times per day" or "times per week")


• the quantity the prescriber is authorizing (how many pills or how much liquid you will receive)


• the number of refills you may receive


• the reason for taking the drug

When your prescriber (the doctor, nurse practitioner, or PA) includes the reason for the drug on the prescription, it provides another layer of information (a redundancy) to help ensure the correct drug is dispensed. 1,400 commonly prescribed drugs appear on lists of regularly confused drugs. Few of these drugs are used for the same purpose. This means that in the event your prescriber doesn't write clearly or the drug name is misread in the pharmacy, the pharmacist performing the final check has another "match point" to help detect an error. In a high-stakes, high-consequence process like medication use, you want lots of checks and double checks. (Medicine may look like candy, but it's not.)

3. Finally, when you pick up a prescription, open the bottle and look at the pills. When you're asked to sign for a prescription, you're likely signing something that says you have no questions and don't require/request additional face time with the pharmacist. Everyone has a least question when picking up a medication, and the question is this: "Did I get the right drug?" Look at the label, or ask that it be read to you. Is this the medicine you expected to get? Is the dose correct? If the name or appearance is different, the pharmacist can explain why (perhaps a generic brand was substituted) or an error that's been set in motion can be detected before you take the medicine home.

Perhaps the most worrisome thing about transitioning to e-prescribing is IT's guiding principle: "garbage in, garbage out." Take a look at this old-fashioned prescription, written just a few months ago for a member of my family.

Although the elements recommended for inclusion in any prescription are easy to list (see above), they are not included on the pre-printed prescription form used by the group of prescribers, a format used by the majority of prescribers in my community. (I blanked out most identifying info but left the "Children's" portion intact to remind myself--and you--that children are among those most at-risk-for-medication-errors and most likely to suffer harm when an error occurs.)

This process is garbage, folks. Just ask the IT person who is trying to automate it.

Where's the engineer of this train wreck?

Every year in the U.S., 1.5 million people are harmed by medication errors, events that add billions of dollars to the healthcare economy. The medication use system we rely on is a lot like a train sent down the tracks without an engineer. Not only was it not "engineered" in the first place, few people on the train understand everything necessary to ensure its safe operation. Worse, most people on board wrongly assume that someone is, indeed, in charge and sit back, assuming they are free to relax and enjoy the ride.

Maximizing the safety of medication use is no short journey. You start with a complex system that involves licensed individuals, crosses the disciplines of medicine, pharmacy, and nursing, is highly regulated, has deep-pocket special interest groups, and requires a high degree of cooperation and communication amongst professionals and consumers. Oh, and to cement your joy, if you include the word "medication" in a sentence, you've just catapulted the instructions out of the range of the fifth grade reading level that health materials are supposed to be written at. ("Medicine," yes. "Medication," no.)

Medications have to be prescribed (or for OTCs, selected by consumers) dispensed, administered, and, in some way, shape, or form, monitored for effectiveness. For warfarin, the rat poison that mitigates inappropriate blood clotting, monitoring involves serial tests run on blood samples. At the other end of the spectrum are birth control pills, where monthly periods suffice. (Sadly, variability is not the friend of reliability.)

Systems engineers speak of "failure points," predictable places where errors are likely to occur. For example, not knowing that a patient takes warfarin when he or she presents for treatment of another condition is a known failure point that can be predicted to result in medication-related harm.

"Failure finding tasks," "performance shaping factors," and "exposure rates," are engineering concepts that rarely make their way into curricula used to prepare healthcare professionals. Yet when it comes to getting desired health outcomes what healthcare professionals know about how a system works may be as important as knowing how a person's system works.

Systems engineers also learn to design work processes to achieve three distinct safety-sensitive outcomes:

1. prevent errors (operative words: barriers, constraints)


2. discover errors set in motion before they cause harm (operative words: redundancy, "failure finding" tasks)


3. mitigate the potential for errors to cause harm (operative words/concepts: recovery, rescue)

There's a host of things that can be done to improve safety when medications are used. But the first step (and remember, this is always the first step) is to recognize that we--all of us--have a problem. If you prescribe, dispense, administer, or take medications, you have a problem: you're riding in a runaway train.

The good news is that the language of systems engineering can be learned, and concepts adopted and adapted to retrofit the medication use system. And you have a role, no matter where you're coming from. I'm going to begin an occasional series, describing specific actions and activities that can be used to strengthen the system. You'll find these posts are indexed with the label "engineering." All aboard? I hope you'll come back soon!