Author: Dale Sahlberg- 1 -

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”

Medication errors are among the most common medical errors, harming at least 1.5 million people every year, says a report from the Institute of Medicine of the National Academies. Studies indicate that 400,000 preventable drug-related injuries occur each year in hospitals. Another 800,000 occur in long-term care settings, and roughly 530,000 occur just among Medicare recipients in outpatient clinics. There is insufficient data to determine accurately all the costs associated with medication errors. The conservative estimate of 400,000 preventable drug-related injuries in hospitals will result in at least $3.5 billion in extra medical costs this year, the committee calculated. A study of outpatient clinics found that medication-related injuries there resulted in roughly $887 million in extra medical costs in 2000 -- and the study looked only at injuries experienced by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.
Source:

Some of the medication error causes are:

1) Drug name similarities:

  • Levoxine (thyroid medicine) being confused with the heart medicine Lanoxin (Digoxin)
  • Lamictal (Lamotrigine) for epilepsy being confused with Lamisil (Terbinafine) for nail infections
  • Avinza (morphine sulfate for pain) being confused with Evista (treat thinning of bones)

2) Dosage errors: ordering Clindamycin 1 mL or Clindamycin 10 mL instead of the intended Clindamycin 0.1 mL. It is prudent to have a number to the left of the decimal even if it is 0 (zero) so an order does not look like Clindamycin .1 ml vs Clindamycin 1 ml

3) If the order description does not include amounts, route and rate, a selection from the main menu can be confusing when it displays on the order entry screen or prints on a document / label.

BRAND NAME DOSAGE FORM ROUTE
? MORPHINE 2 MG INJ DOSE IV
? MORPHINE 4 MG INJ DOSE IV
? MORPHINE 8 MG INJ DOSE IV
? MORPHINE 10 MG INJ DOSE IV

A medication selection from any of the above, when it displays on the order entry screen, will simply look like –

ORDER:

If the description contains more data, the selection is precise:

ORDER:

4) Clicking one line too high or low from a computer screen can also contribute to medication errors:

BRAND NAME DOSAGE FORM STRENGTH ROUTE
? METAMUCIL POWDER 006.000GM PO
? METHADONE TAB 005.000MG PO
? METHERGINE TAB 000.200MG PO
? METHOTREXATE TAB 002.500MG PO

The order should have been METHERGINE but the mouse clicked one line too low:

ORDER:

The unit clerk was so busy that the whole screen was quickly filled out and an order sent to the Pharmacy without noticing the medication was wrong.

METHOTREXATE - Antimetabolite used in the treatment of certain neoplastic diseases, severe psoriasis and adult rheumatoid arthritis. Because it can cause serious effects to the kidneys, liver and blood production it must be used carefully.
METHERGINE - a blood vessel constrictor given to prevent or control excessive bleeding following childbirth.

Is there a way to help a unit clerk or nurse selecting an order to better detect when an order was incorrectly chosen?

YES – by using more than just the eyes. Hearingthe order description can help confirm the right selection was made. A computer VOICE can assist with the order process.

When we enter an order, only one modality is used. Yet we have four (Visual, Auditory, Kinesthetic and Tactile) so it would benefit us to have at least one other modality helping us with order entry.

People have preferences that science has found to be closely tied in with the brain hemispheres - left brain or right brain processing.

Right Brain:

Visual - focusing on images, patterns

Process ideas simultaneously

See the whole first, then the details

'Mind photos' used to remember things and see the picture

Left Brain:

Verbal - focusing on words, symbols, numbers

Process ideas sequentially

Work up to the whole step by step, focusing on details then information is organized

Words used to remember events, store sounds in memory

We can use C++ to create an EXE program to read the order description and SAPI for the voice generation. The Speech Application Programming Interface or SAPI is an API developed by Microsoft to allow the use of Speech Recognition and Speech Synthesis within Windows applications. SAPI can be viewed as an interface or piece of middleware which sits between applications and speech engines (recognition and synthesis).

Because of C++ and SAPI, order entry can now have the best of left and right brain processing … that is fair to all hospital staff members. People who prefer words or people who focus on sounds can enter an order and be presented with visual and verbal cues during the process.

When an order has been chosen and the order entry screen shows the medication,

the computer can also read back the order description (verbal).

In the example where the order should have been METHERGINE but the mouse clicked one line too low, the system said:

Click the link to hear the difference when the order description is “spoken” by the computer.

There is no confusion now that the wrong order was selected since METHERGINE sounds totally different than METHOTREXATE.

Pharmacy example with a full dose and route description:

ORDER:

Here is the EXE file reading the test description for Lab:

Microsoft has extensive documentation on how to use SAPI and add it to your custom programs.

Download the SAPI program from their website (free download) and install it on the personal computer.

Choose the voice you want to hear from the controls for SAPI.

Depending on what Windows software version the computer is running, the default voice is Microsoft Sam but you can also download Microsoft Mary and Microsoft Mike.

You can access the category from the control panel.

Select the option and choose the voice as well as the speed of the voice.

You can preview the voices to see which one is preferred prior to accepting the choice.

Make sure the computer has a speaker and the sound is active (not muted).

When SAPI has been installed, then proceed with the steps below …

EXE FILE

C++ supports procedural programming, data abstraction and object-oriented programming with access to low-level operating system code. That access allows sound to be sent to the internal computer speaker or external speakers.

The steps to create an EXE file are:

a)Write the C++ script to use SAPI to pronounce the order description

b)Compile the script into an EXE file

What is an executable file? It is a file in a format that the computer can directly execute.

Original code is written in a source file (script). To transform a source file into an executable file, it is processed through a compiler. Unlike source files, executable files are in “machine language” and cannot be read by humans. Executable files have either a COM or EXE extension.

There are commercial and “freeware” programs that can write a script and then convert that script to an EXE file.

GOLD has the ability to call EXE files through an EXE controller.

The controller provides the “hook” to another program, such as the SAPI voice program.

The documentation below is for a GOLD pharmacy form – the logic can also be used by any other order entry screen as well (lab, radiology, cardiology, etc.)

Currently, a way has not been found to connect an EXE file to run automatically for a 3270 order entry screen.

DOCUMENTATION

Create a faux field to store concatenated data:

Add the following code to the pre-display section of the GOLD form. This will activate the SAPI program when the screen is first displayed. The computer will “speak” the order description contained in the field “C1202”.

EXE files support command line parameters of the format: YourProgram.EXE “parameter”

Depending on how you write the C++ script to accept parameters, you may need to adjust the parameter section after the

The code EXECUTE [Voice_Messages].ACTIVATE then calls the controller.

Program a C++ script to access SAPI and read the “parameter” that is passed from GOLD. Compile the script into an EXE file and install the file in the location: C:\OasGold

The one I wrote was called:

Change the EXE file name in the GOLD form to the name you call your EXE file.

Command line parameters may need parsing by the EXE program due to spaces between words for an order such as: MORPHINE 2MG IV

Create the [Voice_Messages] EXE controller -

For the program name, enter:

Create a C1202 data listener in case your hospital uses an input / output “C1202” field and allow order description changes. Often the C1202 field is changed to a display only type of field.

Enter the following commands in the data listenerGUI commands section:

Depending on how you write the C++ script to accept parameters, you may need to adjust the parameter section after the

The code EXECUTE [Voice_Messages].ACTIVATE calls the controller.

Make sure the computer has a speaker and the sound is active (not muted).

Now the order entry situation is different for the unit clerk. The order is for METHERGINE and she pulled up the alpha-browse list of medications. The new mouse is an optical mouse that replaced the sticky roller ball former mouse – but the slightest touch moves the cursor a greater distance than before. Consequently, one line too low was clicked.

BRAND NAME DOSAGE FORM STRENGTH ROUTE
? METAMUCIL POWDER 006.000GM PO
? METHADONE TAB 005.000MG PO
? METHERGINE TAB 000.200MG PO
? METHOTREXATE TAB 002.500MG PO

The order should have been METHERGINE but the mouse clicked METHOTREXATE.

However, the system clearly said:

The clerk heard the order description and immediately realized the wrong line was clicked!

She exited the order and returned to select the right METHERGINE medication.

The medication error was corrected due to the order description sound … and this could have saved a life as well.