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Automated drug systems under scrutiny

Computer systems designed to prevent medication errors in hospitals can actually contribute to mistakes, according to a new report.
/ Source: a href="" linktype="External" resizable="true" status="true" scrollbars="true">The Washington Post</a

Computer systems designed to prevent medication errors in hospitals can actually contribute to mistakes, according to a new report.

As more hospitals have implemented automated systems for administering drugs, the number of errors associated with them has risen, according to an annual report on medication errors released yesterday by the U.S. Pharmacopeia (USP), a nonprofit group that sets standards for the drug industry.

"It would seem logical that applying computer technology to the medication use process would have a significant positive impact in preventing medication errors," said Diane Cousins, vice president of USP's Center for the Advancement of Patient Safety. "Yet, depending on the computer's design or user competence, new points of potential errors can emerge."

The findings should help hospitals that have adopted the systems find ways to reduce errors, and those considering such systems to implement them more safely, Cousins said. As the technology matures, the number of errors is likely to decrease and the technology should eventually make hospital care overall safer, she said.

Many hospitals have been adopting computerized systems for administering drugs to patients in an attempt to reduce errors, especially since a landmark 1999 Institute of Medicine report estimated that between 44,000 and 98,000 hospitalized Americans die each year from medical errors of all kinds.

USP has been collecting medication error data from hospitals on a voluntary basis for the past five years. In the latest data, 570 hospitals and other kinds of health care facilities reported 235,159 medication errors that occurred in 2003. Of those, about 20 percent -- or about 43,000 -- involved some kind of automated drug administration system. The group did not have a comparable number from previous reports because it added new categories for computerized medication systems this year, but there was a clear trend of these types of errors increasing, Cousins said.

Errors occurred in all phases of using the systems, including entering incorrect or incomplete information such as patient names, drug doses or lab test results.

The mistakes that occur as a result of these systems tend, however, to be about half as likely to harm patients, the group found.

"What we hope this data will do is identify things that can be designed into the system or designed out of the system," Cousins said.

For example, the data show that many errors occur as a result of the user becoming interrupted or distracted. That suggests the system should be situated in a quiet place where the user can concentrate.

"It shouldn't be in the middle of the patient care unit. There should be an area designated for this -- a quiet area where this can be done in peace," Cousins said.

Other experts said they were not surprised by the findings.

"Technology offers great opportunity to reduce errors, but it's not a panacea," said Kenneth Kizer, who heads the National Quality Forum, a private Washington-based organization trying to improve the quality of health care. "You can't just throw a computerized system in and expect that everything's fixed. It has to be done right. The technology is only as good as the people who use it."