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The Way To Fix Medicine Is Obvious

By: Herb Denenberg , The Bulletin

Here we go again: Another study on preventing medication errors. This one is from the Institute of Medicine, with all the same problems and same solutions identified.

What we need is not another study on medication errors, but a study on why, despite all the studies on medication errors, we don't implement obvious solutions or do so too little and too late.

In fact, the study ought to be on why the health care delivery system can't fix the most obvious problems: How many more studies do we need on the need for hand washing by doctors and others? How many more studies do we need on preventing central line infections (the IV lines that take medication and nutrients directly into the circulatory system)? How many more studies do we need on making the patient a partner in health delivery? How many more studies do we need on mistakes caused by the illegible handwriting of doctors?

A study may be useful if it puts together a picture not previously painted on a problem in need of solutions. A study may also be useful if it generates publicity and mobilizes public and governmental opinions in the direction of recognizing the problem and calling for the solution.

This study, however, from the Institute of Medicine, the organization with the responsibility for advising the nation on improving health, seems to be little more than reinventing the wheel, and it is the same old round wheel that doesn't seem to be going anywhere and, in any event, isn't moving fast enough.

The study does gather statistics that should shock the system and the public into endless howls for reform. But we know those howls for reform aren't on the horizon, and actual reform is even less likely.

Consider some of the statistics on what it calls adverse drug events (ADEs). It says these are often preventable, and they add up to a staggering and killing total each year, just of the preventable variety:

* 380,000 to 450,000 in hospitals.

* 800,000 in long-term facilities.

* 530,000 in outpatient settings.

To further enhance the shock value of these statistics, the study says the numbers are likely to be underestimates. It finally says the total of the preventable ADEs is at least 1.5 million and may be much higher.

The costs are equally shocking - an estimated $8,750 per ADE. Just 400,000 therefore will cost $3.5 billion. And 1.6 million would therefore cost $14 billion. As they say, that's real money in almost any spending environment.

What's the solution? First, the study says patients should be encouraged "to take a more active role in their own medical care." I'm all for that as I just talked to an asthma patient who was in the hospital. The nurse came in with the evening medicine and gave her a pill to take. She said, "That's not the right pill. It is Singulair (for asthma) and not Coumadin (a blood thinner)." The nurse insisted she was right. Fortunately, the patient knew she was right and insisted on a double check. Fortunately, the patient remembered the two pills were not even close to looking like each other: one was square (Singulair), the other round (Coumadin); they were also different colors. So the patient prevented an ADE because she knew her drug regimen. The problem should have been easily resolved as both pills have their names right on them, but in such fine print as to be almost illegible. After the patient related that incident, she remembered another one. The nurse brought a drug. The patient said that's the wrong drug. The nurse insisted it was the right drug. So the patient took the drug, only to find out later it was in fact the wrong drug. So she did learn a lesson from the incident, later applied to the Singulair/Coumadin incident. She told me after the first incident she was told to be understanding of the mistake as the nurse was exceptionally busy. That's the typical response of the health care delivery system to mistakes: They start making excuses instead of figuring out what went wrong, why it went wrong, and how to prevent future mistakes.

The patient should take an active role in medical care. But that pitch reminds me of a commercial for a stockbroker I love: A surgeon is on the phone with a patient who is holding a scalpel. The doctor is telling him how to make the three-inch surgical incision for needed surgery. The puzzled patient asks, "Shouldn't you be doing this?"

Maybe the health delivery system ought to be getting medications right, on its own, without telling the patient to protect himself. They do exactly the same thing with hand washing - telling the patients to tell the doctors, nurses and others to wash their hands before patient contact. But the need to do this does show how severe the problem is. It is an admission that you can't trust the system and you have to protect yourself or you're on the way from conversion from a patient to a statistic - often an injured or dead statistic.

That's not to argue against the informed patient. But I wonder why the study found that educating the patient was the first step. In a sense, that sounds like avoiding responsibility. In any event, it is not a solution. How can those with dementia, those who are unconscious, those who are children, and those who are incompetent start participating in their medical care?

But the study does make some good suggestions, such as providing better ways for patients to educate themselves. For example, it is well known that reference books on drugs and pharmacy brochures on drugs leave a lot to be desired. Isn't it about time the health care delivery system gets that material right?

Another important suggestion is for health care providers, such as doctors, to use new computer technology in prescribing. That eliminates the problem of the illegible handwriting of doctors. It can provide automatic information about whether the dose is right, whether there is some dangerous interaction with other drugs, and all the other variables.

In making this point, the study came up with what I found to be a remarkable statement: "Doctors, nurse practitioners, and physician assistants, for example, cannot possibly keep up with all the relevant information available on all the medications they might prescribe - but with today's technology they don't have to."

That sentence ought to shock patients into intensive self-education programs. It says the prescribers can't keep up with relevant information. What's more, it says they don't have to. I'm all for new effective technology. But I'm not prepared to admit that doctors can rely on new technology instead of keeping up with relevant technology. For example, what do they do when computers break down? I remember many a day at WCAU-TV in Philadelphia when the computers would go down. There was always a rush to my office, as I had the only typewriters in the building. But what happens when the computers at a hospital go down. The doctor comes to the patient and says, "I'm sorry, we can't deliver the medicine you need to save your life. That's because our computers are down. Furthermore, I can't keep up with all relevant information and I therefore must rely on computers. When the computers are back up again, if you're still alive, you'll get your medicine." Maybe the computers should be saying to the doctors, "Hey, aren't you supposed to know this stuff, too?"

Here's another recommendation: drugs ought to be labeled with distinctive names so they are not so frequently confused. This is an old problem. I remember reading pharmacy magazines 20 years ago or more that would publish long lists each month of medicines with names likely to be confused. Why hasn't this been straightened out before, and why should we believe this is the study that will finally lead to action?

One of the study's concluding remarks is indeed noble: "More generally, all health care suppliers should seek to become high-reliability organizations preoccupied with improving medication safety." Isn't that a nice touch? Perhaps they should have said: Warning to patients: Health care suppliers are not high-reliability organizations and they are not preoccupied with improving medication safety. Perhaps they are preoccupied with improving their bottom line or with aggressive advertising and marketing. So proceed with caution, question everybody and everything, because you're life is in jeopardy, and not just from your medical condition.

Based on the historical record, don't expect a decline in the number of preventable medical errors. What you can expect is an increase in the number of studies telling us something must be done about stopping these preventable errors and telling us again what all experts already know about stopping them. You have to start to ask whether the studies are designed to bring about reform or are just another excuse for inaction.
Herb Denenberg, a former Pennsylvania insurance commissioner and professor at the Wharton School, is a longtime Philadelphia journalist and consumer advocate. He is also a member of the National?Academy of Arts and Sciences. His column appears daily in The Bulletin. You can reach him at


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