Patient Safety Authority reports 813 wrong-patient medication errors in Pa. over six-month period in 2011.

It might seem like overkill to some, but there’s a reason why doctors and nurses ask patients their names and other identifying questions over and over again: They’re ensuring that the right medicine and dosage gets to the right patient.

Even with multiple verifications, however, hospital clinicians still make mistakes. The Pennsylvania Patient Safety Authority logged 813 wrong-patient medication errors over a six-month period in 2011 and found that they occur at every step of the process — from ordering the medication to filling the prescription in the pharmacy to delivering the correct dosage to the patient.

“There’s a lot of breakdowns in the processes of health care,” said Matthew Grissinger, who co-wrote the report for the authority. “It’s not about people failing; it’s about bad processes.”

Grissinger’s analysis of self-reported errors from 270 hospitals, birthing centers and ambulatory medical centers across Pennsylvania showed that wrong-patient medication mistakes occurred most frequently during what he called the administration of drugs. Those errors commonly involved nurses obtaining the wrong medication from drug storage areas, including automated dispensing cabinets.

Most commonly, the report said, two patients were prescribed the same medication, and one received the dose intended for the other.

Nurses at times also failed to properly check a patient’s identity, it said.

While these were the most common mistakes, Grissinger said he wanted to dispel the myth that wrong-patient medication errors primarily are a nursing problem.

For example, Grissinger found that some mistakes occurred when a paper medication order was improperly transcribed onto a patient’s record. In about half of the transcription error cases, the mistake was caught by a pharmacist or nurse, the report said.

In addition, about 5 percent of the errors occurred when drugs were being dispensed. According to the report, they most often occurred when a patient-specific label was applied to an incorrect medication package.

It’s difficult to put 813 errors in six months in perspective, because there is no other publicly available ranking, Grissinger said. The safety authority has a database of about 44,000 medical errors, he said.

The good news, according to the self-reported data, is that few wrong-patient medication errors resulted in patient harm. Using a standardized code for medication errors, the data showed that only four of the 813 errors resulted in patient harm. In all four cases the harm was temporary, it said.

It’s up to the hospital to put processes in place to reduce wrong-patient errors, said Patrick Ferguson, pharmacy director at St. Luke’s University Health Network.

The network has been operating for five years with an electronic order entry system, he said, already complying with one of Grissinger’s recommendations. With that system, a physician can order medications on a form that goes directly to the pharmacy, eliminating one handoff. Nurses have to verify the order before it can be dispensed, he said.

The most effective safety mechanism, Ferguson said, is bedside bar scanning. When medicine is prescribed, nurses have to scan the drug order, scan the patient’s bracelet and then scan their own identification before giving it to the patient. That has cut deeply into the problem, he said.

“I can’t remember the last time I can think of a med being given to the wrong patient,” Ferguson said.

The report notes that the national accrediting agency, the Joint Commission, recommends that health care practitioners use at least two patient identifiers — not the patient’s room number or location, because patients can share rooms — before dispensing medication.

It also says physicians should limit the use of verbal orders.

Patients also can play a role in protecting against medication errors, Grissinger said. Hospitals should educate patients on their medications, how much they should receive and how clinicians should review the prescription and their identification before issuing the medicine, he said.

“From the minute they walk into the hospital,” Grissinger said, “hospitals should teach patients about their role in helping to prevent medical errors.”

For example, patients should be encouraged to speak up if they see an IV bag with another patient’s name on it or if a nurse fails to scan their bar code identification before administering medication, the report said.

Some patients might find the checking and rechecking of a patient’s identity annoying, but their active involvement in their care will help reduce errors, Grissinger said.

From The Morning Call, by Tim Darragh