Practice of Medicine


Tips for Avoiding Medication Errors

In this episode, Steve Adubato, PhD, speaks with Christopher Holstege, MD, chief of the division of medical toxicology and professor of emergency medicine and pediatrics at the University of Virginia and a member of the medical faculty at MagMutual. Dr. Holstege describes the common sources of medication errors, explains the difference between medication errors and adverse drug reactions, and provides recommendations on how to ensure patients get the right medications every time. He discusses the importance of communication and checks and balances among the healthcare team, why there is reporting bias with medication errors, what to pay attention to when administering pediatric medications, and other important tips.
Please note: This podcast was originally a production of MDAdvantage, which is now part of the MagMutual family of companies.
Release Date: 8/9/2023; Recorded Date: 3/7/2023
Podcast Transcript

ADUBATO:  Hi everyone, welcome to the MDAdvantage podcast. This is Steve Adubato.  MDAdvantage is proud to now be a part of the MagMutual family. MDAdvantage physicians and their practices will continue to receive exceptional protection and support, now backed by the strength and stability of MagMutual. Our podcast is honored to be joined by Dr. Christopher Holstege, who is chief of the division of medical toxicology and professor of emergency medicine and pediatrics at the University of Virginia, and a member of the medical faculty at MagMutual Insurance Company. Doctor, it’s great to have you with us. 

HOLSTEGE:  Hi, Steve. 

ADUBATO:  Today’s topic is medication errors. First of all, how big is the problem? And then we'll talk about the reasons for it.

HOLSTEGE:  Yes, that's certainly a problem. We're using a lot of medications, both from the hospitals and out in the community when patients are at home, so medication errors are certainly a concern that we have as we care for our patients.

ADUBATO:  Talk about your background as a toxicologist.

HOLSTEGE:  I'm a medical toxicologist. I take care of patients who are poisoned, and that can go anywhere from intentional to unintentional. We care for patients who may have adverse drug reactions in the hospital. We also care for patients who may have gotten medications where there are drug errors that occurred, in hospitals or out in the community. 

ADUBATO:  I want to jump into something because it's anecdotal but it's relevant. Literally this morning I happened to be at a local hospital to go for a blood test, and I went in, signed in and gave all my information. They put this band on me, and I went to get the blood test in the lab. The lab tech said, “Hey wait a minute, that's not the right wrist band for this test.” I said, “What do you mean?” She called downstairs and they said, “Oh, yeah, it's the wrong band,” etc., etc. So I asked her, because I knew I was doing this podcast with you today, I said, “What would happen if it was the wrong wrist band?” And she said, “Well, your wrist band and your blood work wouldn't match up and you could get the blood work of someone else.” I said, “Seriously?” So, ultimately, the point here is that I said, “What's the biggest reason for that sort of error?” She said, “Miscommunication, and, frankly, not attending to details.” Please respond to that, doctor. Not about my situation, but the larger question of miscommunication and not attending to details.

HOLSTEGE:  Medicine is a big business. A lot of patients come through healthcare and we need good communication to make sure that they get the right treatments and specifically the right medications. That goes anywhere from the prescribing provider, when they write the prescription, to the hospital pharmacist who is dispensing it, and the nurse who is potentially administering it. It is very important to have that communication. The electronic systems have really been shown to be of benefit to prevent errors. If you think about the old days, when we used to hand write prescriptions, it was rife with error. Physicians were known for their terrible penmanship. I think things have gotten better, and yet more complex, because we have so many medications. There are so many complex treatments now compared to the past. 

ADUBATO: If you're listening right now, we are in fact talking to Dr. Christopher Holstege. This is Steve Adubato of the MDAdvantage podcast, powered by MagMutual. 

I want to follow up on something. You talked about these errors, all kinds of errors, and I mentioned my anecdotal situation. What are some of the most common medication errors, doctor, that we should be aware of as patients, but also for physicians who are listening right now?

HOLSTEGE:  We want patients to be well informed and well educated on this. They should be asking questions of their physicians, and I like it when my patients do. It shows that they're paying attention. Some of the common errors that occur include inappropriate medication for the condition being treated, incorrect dosage or frequency of administration of a medication, wrong routes, failure to recognize drug/drug interactions. If you think about some of our older patients who might be on 10 or 15 medications, it is really common to get drug/drug interactions. If you have a known allergy, not having that documented and not paying attention to that and being given a medication that might cross react. Also, there can be a lack of monitoring for drug adverse effects. Many of our medications are very good at what they treat, but there can be adverse effects and physicians should be attuned to that. And missed or late dosing errors in the hospitals when we administer.

And then simply it comes to communication. How do we communicate with each other in a busy hospital environment, specifically, but even in the community practice? You want open communication. You want a nurse to be able to question back a physician or a pharmacist to call and say, “Hey, I have a question about this.” I like it when they do that. I like it when my nurses in the emergency department, for example, ask me, “Why are you giving that medication?” That just shows that they're attuned to thinking through what they're administering.

ADUBATO:  I'm going to follow up on something. You mentioned adverse drug reaction. Define the difference, if there is one, Dr. Holstege. Is there a difference, or what is the difference, between a medication error and an adverse drug reaction?

HOLSTEGE:  Yes, there is a difference in how we look at those. A medication error is any preventable event that occurs in the process of ordering or delivering a medication, regardless of whether an injury occurred, or the potential for an injury was present. We should have been able to predict that. An adverse drug reaction is a response to a drug which is not anticipated and is unintended. Something that does not typically occur when you give that drug and so it would not be predictable. 

For example, say I have an allergy to a medication. An adverse drug event would be that I gave a medication to a patient, even though it is documented that they're allergic to and it causes an allergic reaction. An adverse drug event would be that I'm giving a medication for the first time, and say it's penicillin, and they have an allergic reaction to that. That would not be anticipated, but as a good clinician I'm aware that that can potentially occur and I know what the proper treatment is, and then making sure that gets into their chart. 

Medication errors can occur in the absence of injury to the patient, too, and I think that's where this gets really challenging, because there's some reporting biases as we look at the literature on this. I'm much more prone to report an error that occurs that does harm as opposed to an error that doesn't do harm and may be very minimal. I think that gets to be a little bit challenging when we look at the literature.

ADUBATO:  It's interesting you mention the degree of harm. Some medication errors are life threatening?

HOLSTEGE:  Yes, they certainly are, and people can die, which would be the worst of all things to occur from administering an inappropriate medication or committing a medication error. Fortunately, if you look at the literature, this occurs less than 1% of the time. There's a bit of a reporting bias, so if you look at some of the percentages in the literature, I would say those are a bit larger than what is really out there because there are so many other minimal errors that occur that just don't get reported. However, you can have some pretty life threatening injuries occur, which are thought to be less than 10% of cases. Depending on how you define life threatening, it can include things like errors that occur even to mothers who are pregnant that can potentially lead to birth defects. There's a number of ways to look at this, and it's pretty complex when you look at the literature. But again, less than 1% end in fatalities, thankfully. We certainly don't want that number to grow. We want to keep significant harm less than 10%, depending on how we define that.

ADUBATO:  What advice do you have for physicians who obviously, coming from a good place, want to avoid medical errors, but things happen. What is the best way to avoid those things happening?

HOLSTEGE:  Yes, and you already identified one, Steve. You mentioned the specific patient identifiers, and these are really important. These bar codes that we put on wrists are read back by nurses to make sure that you are actually the person who is supposed to be getting the medication. Very important, and that's where so many electronic records and databases are really helpful.

We always should verify allergies and reactions that patients have had in the past before a medication is given. Highlight what diagnosis they have, what kind of conditions, because some medications may be contraindicated in certain conditions. We as clinicians always need to make sure we update current medications. So often we get patients who come in to the emergency department and we don't know what they're taking. Either the list just hasn't been updated, or they're seeing multiple providers. That gets really challenging regarding drug interactions. We really want to make sure height and weight measurements are correct, especially when we get into the pediatric population. Weight becomes very important, and I'd also argue the same for the elderly population, too. All populations, but we're not always good about getting the weights, and the same dose is not necessarily used for everybody. 

ADUBATO:  What do pediatricians specifically need to be thinking about and paying attention to that would differ from a non-pediatrician physician dispensing medication for an adult patient. What are some of the keys? 

HOLSTEGE:  The key one is weight. 

ADUBATO:  Weight? Weight is number one? 

HOLSTEGE:  Yes, from my perspective. If you look at the literature, it's not considering the weight or doing your calculations incorrectly. This is certainly true in emergent situations.  Again, it depends on the specialty. If you look at emergency medicine, for example, if I have a kid who's coming in who's really sick and needs resuscitation, people are moving fast and you can be off by a factor of 10 on your calculation. That can certainly cause an adverse event to occur. Think about a kid who comes in with anaphylaxis from a bee sting that we have to give epinephrine to. We want to make absolutely certain that the dose of epinephrine is spot on, and that we're not giving the wrong dose. 

Consider opioids. We have an opioid crisis in this country. We have to make sure the dose is correct. The opioid doses vary depending on which opioid we give. We've seen plenty of errors in that arena. We have to take into context, for example, if I have a patient who has kidney failure. They can't have morphine, but they can have other drugs that are metabolized by the liver without active metabolites that get eliminated. So I always teach my medical students and residents that you have to pay attention to organ dysfunction, too. 

In pediatrics, again it is really important that we're communicating well with the teams, and that we're reading back what the orders are. Again, so much of it is weight based. I can't stress enough the importance of that for young kids. The last thing with kids, if you get neonates, such as, for example, my grandson who was born prematurely, their organs aren't fully developed. That makes it even more complex in terms of what medications they can get, and that's where we have neonatologists who know those issues that occur. But certainly family medicine doctors and others need to know about these really young kids who are premature, regarding the differences in metabolites, metabolism and what they should get. 

ADUBATO:  No detail too small when you're dealing with such important issues. Last question from my perspective. I'm a long-time student of leadership and communication, and one of the concepts in leadership that I adhere to is ownership, ownership of mistakes, extreme ownership, as the book Extreme Ownership talks about. Now, why is this relevant to this discussion? Well, many physicians in hospitals serve on multi-disciplinary teams. There are nurses, hospital pharmacists and a range of colleagues they're working with. Doctor, who is ultimately responsible for the delivery of medication? And it's not about blame, it's more about accountability and responsibility. Who is ultimately (and I use too many sports metaphors) the quarterback of this team?

HOLSTEGE:  Yes, it's a multi-disciplinary team. We all work together. But the physician is still the lead of the team, and I have taught my residents this, too. We need to pay attention about what’s going on with the rest of the team, and we are going to be seen as potentially responsible. Even if it's a nursing error that occurs, we may still get named in a lawsuit, even though we weren't around when the error occurred. But it's being aware of all parts of our team. If the analogy is quarterback, I would say the physician is the quarterback of the team, and it's exceedingly important that we are constantly in communication. Likewise, Steve, as you mentioned with some of the publications that have been out there, my team should feel comfortable communicating back with me. If I make an error, I certainly want them to catch it and talk to me about it. My pharmacists are fantastic. Their expertise is just phenomenal in the emergency department where I work, as well as my nurses. I've had some really good catches from the team just questioning. They need to be able to question and go back and ask the question of our licensed independent practitioners who are prescribing medications, and especially the physicians. 

ADUBATO:  Finally, Dr. Holstege, we’re talking about creating a culture of open communication, honest communication, two-way communication, multi-faceted communication. It sounds like you're talking about a physician leader who creates such an environment where he/she/they not only check, double check and verify, but also on the other end are very open and receptive to that feedback. I cannot thank you enough. On behalf of the MDAdvantage team, I want to thank you so much, doctor, for joining us. We appreciate it. 

HOLSTEGE:  Steve, thank you. It's great to have the opportunity. 

ADUBATO:  On behalf of MDAdvantage and MagMutual, this is Steve Adubato. We thank you so much for listening. Check us out next time.


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