Is technology the key to preventing medication errors?

A friend and I were having a casual conversation when the issue of a recent medication error crept into the discussion. The error occurred at a Walgreens where Durasal, salisylic acid 26% for wart removal, was mistakenly filled in place of Durezol, difluprednate, a topical corticosteroid for the eye. The danger associated with such a mistake is immediately obvious; salicylic acid can cause serious damage to the eyes.

I don’t know the details of how the error occurred, but my first thought was how in the world something like this could happen. It seems so unlikely that a wart remover could be mistaken for an ophthalmic drop. Then again, one only has to look at the image below to understand the potential for such a mistake. Not only is the packaging for the two products similar, but the brand names sound virtually the same.

It’s possible that employing the right type of technology could have averted such an error, but then again maybe not. Depending on the situation, technology may not have been the answer. While technology plays an important role in medication safety, there are still many places in the medication use process for things to go wrong.

The medication use process is complex. It consists of several steps, including from the time a prescription is conceived in the mind of a physician to when the prescription is ultimately utilized by the patient. A medication error can occur in any one of those steps. To confound matters, preventing a medication error in one phase of the process does not necessarily prevent the error from reaching the patient as each area of the process can act independently of the others. A physician using an electronic order entry system, for example, may inadvertently order the wrong medication and the pharmacist and patient would never know. Or the physician could order the correct medication and the pharmacy could fill it incorrectly. Or the physician could order it correctly and the pharmacy could fill it correctly only to have the nurse or patient administer the wrong dose. And so on. The variables are staggering.

Technology can certainly be used to cut the number of medication errors that reach the patient, but common sense, increased awareness and improved processes play an integral part of medication safety as well. Clinical decision support software, bar code picking in the pharmacy, bar code administration at the bedside, and etc. all act as barriers between medication errors and the patient. However, simple things such as writing the reason for the medication on the prescription (“for wart removal”), or carefully consulting with the patient prior to dispensing the medication (“do you know what this medication is for?”), or even using the generic name instead of the brand name (salicylic acid 26% vs. difluprednate) on the prescription order can go a long way in decreasing the likelihood of errors reaching the patient. After all, what pharmacist would dispense salicylic acid 26% for ophthalmic use? Not many I can assure you.

So back to the original question, is technology all you need to prevent medication errors? Sadly, the answer is ‘no’. While technology is important and will continue to be a foundation for improved patient safety, we should remember that common sense and proactive thinking will go a long way in preventing medication errors. Technology is but a tool that we use to help us do our jobs, not an excuse to drop our guard when it comes to the medication use process.

I believe technology will eventually lead us to the best possible patient safety model, but we’re not quite there yet. I believe we have some work to do. “For safety is not a gadget but a state of mind.” (Eleanor Everet)

This is the short link.