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Improving Patient Safety In Rural Hospitals

Improving Medication Safety


Steven Rough, M.S., M.Ph., Director of Pharmacy Services, University of Wisconsin Hospital and Clinics, Madison, WI.

Research Summary

Steven Rough, Director of Pharmacy Services at the University of Wisconsin Hospital and Clinics discussed the research that explains the scope of the medication error problem. He also highlighted ten medication safety recommendations published by the Wisconsin Patient Safety Institute (WPSI) and supported each recommendation with research. Finally, Rough summarized by offering suggestions for practical ways that Wisconsin health care providers can improve safety in the medication use process.

To set the context, Rough reiterated some common patient safety related facts drawn from the Institute of Medicine's report, To Err is Human: Building a Safer Health System (IOM, 1999):

  • Medical errors are the 4th—8th leading cause of death in the U.S.
  • Medication errors account for >7000 deaths/year.
  • Two out of every 100 patients admitted to the hospital experience preventable adverse drug events (ADEs).

And from a JAMA article by Bates, et. al. (Bates, 1997):

  • 28% of ADEs are preventable
  • Preventable ADEs result in additional lengths of stay of 4.6 days, and increase costs by $5,857.
  • Annual costs attributable to preventable ADEs = $5.6 million (700 bed hospital).

Rough explained that 56% of errors resulting in preventable ADEs occur during the ordering process, 34% occur during the administration process, 6% in the transcription process, and 4% in the dispensing process (Bates, 1995).

Rough presented a chart outlining the ten patient safety recommendations published by the Wisconsin Patient Safety Institute and his personal ratings on the difficulty to implement and the amount of supporting research evidence.

Recommendation Difficulty to Implement Supporting Evidence
1. 24-hour pharmacy coverage L I
2. Computerized prescriber order entry (CPOE) H I
3. Unit dose distribution system L I
4. RPh managed IV admixture preparation L II
5. Generic drug names on labels L II
6. Computer screening prior to dispensing M I
7. Bar-coding system for medication packaging & administration (point of care technology) H I
8. High-risk medication policies & procedures L II
9. Eliminate commonly misinterpreted symbols and phrases M III
10. Include intended use on all drug orders, labels, and packages M III
Difficulty to Implement:
L = Low, M = Medium, H = High
Supporting Evidence:
I = Substantiated research (randomized trials)
II = Case studies (e.g., lay press or professional literature)
III = Expert opinions

Dr. Rough discussed several of the recommendations for which, in his opinion, there are substantial research findings. The following is a brief synopsis of the recommendations most strongly supported by research (i.e., given a rank of I). For an explanation of the research about the remaining recommendations, go to the Appendix: "Medication Safety Recommendations for Wisconsin Health Care Providers."

Recommendation one, 24-hour pharmacy coverage by a registered pharmacist, is increasingly important given the increasing complexity of treatment for inpatients, the increased number of medications per patient, increased frequency of change in medication use, and increased potency of modern medications. One study revealed that implementing such coverage has result in a 66% decline in adverse drug events ADEs for ICU patients and an annual savings of $270,000. Rough stressed that this recommendation is one of the strongest and is supported by ample literature showing a positive cost-benefit relationship.

The second recommendation, to implement a computerized prescriber order entry (CPOE) system, is also widely supported by research, according to Rough. A CPOE system allows physicians and other prescribers to type prescriptions in to a computer and send them directly to the pharmacy, rather than using pencil and paper methods. Ideally, CPOE can be used to order medications, labs, and other diagnostic tests, and will compare drug orders against standards for dosing, possible allergic reactions, and will warn prescribers about potential problems. In some cases, CPOE has resulted in a 55% decline in overall medication errors, 17% decline in preventable ADEs, and 84% decline in non-intercepted potential ADEs (Bates, 1998). Rough explained that while the benefits are great, it is important that the system chosen is compatible with the providers and hospitals that will be using it. He stressed that it is key to involve physicians in the process of choosing and designing a system, since they will ultimately be the ones using it. He also explained that implementation can be a long process and that health systems should plan on at least five years for system development and enhancement.

The third recommendation, unit dose distribution, is also strongly supported by research. Unit dosing involves packaging medications in single unit packages so they can be dispensed in a ready-to-administer form. The advantages to unit dosing include a reduction in medical errors, a decrease in total costs due to waste and expired medications, and less clutter and more efficient use of nursing personnel. When compared to multidose medication administration, unit dosing reduced errors by 81% (Means, 1975).

The next recommendation supported by ample research is number six on the list, or computer screening prior to dispensing. Such systems are designed to aid clinicians in making diagnostic and therapeutic decisions in patient care and are able to make patient-medication specific recommendations. Rough explained that this type of system still needs to be developed further but holds great promise in:

  • Simplifying access to data needed to make decisions.
  • Providing reminders and prompts.
  • Assisting in order entry.
  • Assisting in diagnosis.
  • Reviewing new clinical data.
  • Alerting when important patterns are recognized.

When implemented effectively, computer screening has been shown to decrease adverse drug events by 66% (Raschke, 1998).

The seventh recommendation, implementing a bar-coding system for medication packaging and administration (point of care technology), is the remaining recommendation supported by the strongest research base. Bar coding has the advantage of encouraging the safe and accurate administration of medicines to the right patient by drug, dose, time, and route. It also increases accuracy of documentation and increases staff efficiency. It has been shown in studies to reduce overall medication errors by 71%, omitted doses by 52%, doses given at the wrong time by 43%, and the wrong dose administered by 33% (Puckett, 1995). It does have limiting factors, however. To be effective it requires that all medications are bar-coded and currently there is a lack of manufacturing bar coding standards. Implementing the system can be cost-prohibitive and necessarily require training and an alteration in nursing and pharmacy practices and workflow.

AHRQ's Evidence-based Practice Program's report published in July 2001, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (EPC report: also discusses the existing research evidence related to many of the WPSI recommendations. Go to Section A. "Adverse Drug Events" for the following chapters:


Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD.

American Hospital Association. AHA Guide to Computerized Physician Order-entry Systems. November 2000. Available at:

Bates DW, Teich JM, Lee J, et al. The impact of computerized prescriber order entry on medication error prevention. J Am Med Inform Assoc 1999 Jul-Aug 6;(4)313-21.

Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order-entry and a team intervention on prevention of serious medication errors. JAMA 1998 Oct 21;280(15):1311-6.

Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA. The costs of adverse drug events in hospitalized patients. JAMA 1997 Jan 22-29;277(4):307-11.

Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995 Jul 5;274(1):29-34.

Bridge Medical. The Effect of Barcode-enabled Point of Care Technology on Medication Administration Errors. Available at:

First Consulting Group. A Primer on Physician Order Entry. California Healthcare Foundation. September 2000. Available at:

Institute for Safe Medication Practices. A call to action: eliminate handwritten prescriptions within 3 years! Available at:

Institute of Medicine (Kohn LT, Corrigan JM, Donaldson MS, ed.) To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

Kaushal R, Bates DW, Landrigan C, McKesnna KJ, Clapp MD, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 Apr 25;285(16):2114-20.

Means BJ, Derewicz HJ, Lamy PP. Medication error in a multidose and computer-based unit dose drug distribution system. Am J Hosp Pharm 1975 Feb;32(2):189-91.

PSW Medication Use Practice Standards to Maximize Patient Safety. April, 2001. Available at:

Puckett F. Medication-management component of a point-of-care information system. Am J Health-Syst Pharm 1996;52:1305-9.

Raschke RA, Golihare B, Wunderlich TA, et al. A computer alert system to prevent injury from adverse drug events. Development and evaluation in a community teaching hospital. JAMA 1998 Oct 21;280(15):1317-20.

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