Rural hospitals look to reduce mistakes in dispensing medication

Posted: Monday, August 04, 2003

Robert Albertson, the chief pharmacist for Alaska Pioneers' Homes, tells the story of a doctor who told a 90-year-old woman suffering from dementia to stop taking a certain drug she had been prescribed.

The woman never mentioned it to the assisted-living home's staff and she continued to take the drug, which thins the blood. The staff noticed something was wrong only when she was bleeding. Lesson: Doctors should write down medication instructions and give a copy to the pharmacist.

Mistakes in prescribing or giving medications are a national problem that sometimes harms patients or kills them, and it's a concern in rural Alaska, according to the Alaska State Hospital and Nursing Home Association.

About 20 health care providers, many of them rural nurses, attended the association's conference Thursday and Friday in Juneau about how to avoid medication errors.

Hospitals and clinics in small towns and villages don't always have a pharmacist, and often nurses must locate medications in a "drug room," figure out the right dosage, mix intravenous solutions and give the drugs.

Medication errors include not administering drugs that should be given, or administering the wrong medicine or the wrong dosage or the right medicine but at the wrong time.

"There's a national movement on quality of patient care and patient safety," said Randall Burns, director of the association's small hospital performance improvement network. "Certainly the quality of care, given the resources we have, is an issue that all of us face."

Nationwide, one in 131 outpatient deaths and one in 854 inpatient deaths are attributed to medication errors, said Marion Slack, an associate professor of pharmacy practice and science at the University of Arizona.

The Institute of Medicine estimated in 1999 that medication-related errors cause 7,000 deaths a year in the United States.

Certainly, medication safety issues exist everywhere. Slack said errors can occur because pharmacists or nurses confuse similar-sounding drug names or similar-looking packages of medications.

But rural areas have characteristics that may contribute to medication errors.

Rural patients may not read or speak English well or at all, and may not understand what health care providers are telling them about medications, Slack said.

The Bristol Bay Area Health Corp., based in Dillingham, serves about 8,000 people in 33 villages spread over 44,000 square miles, said Sue Mulkeit of the Native health corporation. Some elders in those villages don't speak English, she said. Some children don't speak English until they get to school.

Cordova gets a summer influx of Filipino and Japanese cannery workers, many of whom don't speak English, added Gretchen Zolldan of the Cordova Community Medical Center.

"We may not understand what their allergies are, or what their specific medical complaint is," she said in an interview.

The isolation of Alaska towns and villages makes it harder for health care workers to be trained in medication safety or to have access to people experienced in the issue, Slack said.

Some errors happen in rural areas because health care workers don't see a particular type of treatment very often, and they don't know what the typical doses of medication are, she said.

Albertson said a large part of a pharmacist's job at a hospital is reviewing medications based on his or her knowledge of drugs and the patient's condition, and talking to patients and physicians.

The association's small hospital performance improvement network may apply for federal grants to have a pharmacist on-call who could be consulted by rural hospitals and clinics that don't have a pharmacist on site, Burns said.

It would give nurses an opportunity to ask questions if they have doubts about the appropriateness of the drug or its dosage. Building in second checks is one of the ways mistakes get caught, participants said.

"Safety is a system characteristic," Slack said. "You can't tell people to be safe. It has to be something that comes from a system."

The Cordova Community Medical Center doesn't have a full-time pharmacist. It consults with the local retail pharmacist, who may not be familiar with the drugs given in hospitals and for acute care, said Zolldan, the center's nursing director.

"So the nurses and physicians rely a lot on using reference materials, rely on their education," and sometimes call pharmacists at large hospitals in Anchorage for information, Zolldan said. "Sometimes it gets a little harried when you're in an emergency situation."

Institutions also are looking for systematic ways to dispense drugs.

The six Pioneers' Homes in Alaska moved to a centralized way of dispensing medications in 1997, rather than having them bought in each community, Albertson said.

The new system gives patients their drugs on cards with each pill individually wrapped in a bubble, so it's easy to see if the daily dose is taken. The cards contain an explanation of what the drug is for, so the person giving it to the patient can check that it applies.

"You can't look at the tail end of the assembly line to bend the car door to make it a quality door," Albertson said, referring to the need to redesign systems to reduce mistakes. "You have to do it at the front end."

The Alaska Native Medical Center is testing a telepharmacy program in rural villages. A pharmacy at the medical center in Anchorage would accept prescriptions by phone, fax or secure computer lines. The orders would be reviewed by a pharmacist for their appropriateness and safety.

The pharmacist also could speak to health care workers by phone or e-mail, and to patients as well. A videoconferencing phone is being tested.

The drugs would be dispensed from bins in the village clinics in an automated system, based on a bar-coded label.

Most medication errors occur between the doctors and the pharmacists, said Laraine Derr, head of the Alaska State Hospital and Nursing Home Association. Sometimes the cause is poor handwriting.

In the Alaska Health Passport Project, the association is seeking $3 million in federal funds to try in Juneau plastic "smart cards" that would contain the patient's retail medication history, insurance information and emergency medical and immunization history.

Doctors would enter the drug's name on the card through a computer, eliminating unclear handwriting. Pharmacists would read the information. Doctors and pharmacists would know what drugs had been prescribed by other doctors, as well.

Considering the transient work force in Alaska, such as in the fishing industry, the smart cards would be a good way to keep track of patients' medications, Zolldan said.

But Albertson cautioned that documents, whether on a 3x5 card or a smart card, won't replace a physician or pharmacist talking to patients about their medical history.

"The best computers are skilled history-taking human beings who talk to human beings," Albertson said.

Eric Fry can be reached at

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