Pharmacist explores new methods to reduce medication errors

Something is killing patients in hospitals across the country – hundreds of thousands every year. Beju Shah, PharmD, a clinical informatics pharmacist at MUSC, thinks he knows how to stop it and is on a mission to keep patients safe.

When the Institute of Medicine published “To Err is Human,” its 1999 report on medical errors, health care professionals were shocked. Nearly 100,000 people die every year because of preventable mistakes, the report claimed. Doctors challenged its findings, fueling debate and controversy in the health care industry for over a decade.

We now know that report was incomplete. The numbers are actually much higher.

According to researchers at Johns Hopkins University, medical errors are the third leading cause of death in the United States. Ranking behind only cancer and heart disease, and well ahead of diseases like stroke and Alzheimer’s, they claim more than a quarter-million lives every year. 

Perhaps the most common type of medical error is when patients are given the wrong dose of a drug or the wrong drug altogether.

“It’s hard to believe such errors still happen in the age of barcodes, with computers checking and double checking our work. But they do,” Shah said. “In our health system, we may scan a drug’s barcode eight to 10 times before it gets to the patient. We’ve got great safety nets, but if we don’t use them effectively, then we’ll have issues downstream.”

There are a lot of safety nets in place, but many points of potential failure as well. Since 2004, the U.S. Food and Drug Administration has mandated that medications be labeled with identifying barcodes, a recommendation put forward by the “To Err is Human” report. But drug manufacturers often label drugs in bulk, which means pharmacists must repackage and relabel them before they can be dispensed. In addition, manufacturers change barcodes from time to time to update drug information, but providers don’t always find out in a timely manner when they do. This can cause headaches – metaphorical ones for clinicians and possibly real ones, or worse, for patients.

“This was a broad mandate which did not ensure the quality of the barcode on the package,” Shah said. “Many hard-to-read barcodes do not scan easily for end users – white, translucent barcodes or barcodes printed on curved bottles, for example. There are far too many drugs that come through our supply chain that aren’t recognizable because of outdated or unreadable barcodes. That’s a massive chasm – not a gap, a chasm – in the safety net.”

Shah’s bold idea is a medication early warning system that proactively detects when drugs slip through the net and sounds an alarm, preventing dangerous and costly errors before they happen.

Realizing he was on to something, Shah turned to Intuit’s QuickBase, a “citizen development” software platform designed to allow anyone with a good idea to build a working app, even without a background in writing code. If the safety net had holes, he’d find a way to patch them. 

Even with a well-designed system, compliance can still be an issue, said MUSC Health Patient Safety program manager Stephanie Sargent, RN. Shah’s system addresses that too. “Before a patient is given any medication, the doctor or nurse should scan the medication and the patient’s armband to ensure the right dose of the right drug is being given to the right patient, at the right time, by the right route,” she said. “But, when medications have a barcode that can’t be scanned, or isn’t in our system, then that step gets skipped, and we end up circumventing a very important safety check.”

Eliminating barcode errors, Shah said, eliminates one barrier to compliance and reduces human error in that step of the process. Rather than rely on users to report barcode issues manually, Shah’s application automatically consults electronic health records databases to make sure drugs in the pharmacy match their inventory records and that they are labeled correctly with up-to-date barcodes.

“With this application, we can move away from self-reporting barcode errors, which is a reactive approach, toward proactively and automatically finding problems before they even enter our system,” he explained.

Designing this type of system didn’t come out of left field for Shah. Before deciding to go into health care, he pursued degrees in computer science and business administration and got his start working with tech startup companies created by faculty and students at the University of South Carolina. He said that experience was crucial to his current project.

“To succeed with something like this, you have to have a startup mentality,” he said. “You have to be willing to try things and fail.”

That can be difficult at large organizations that are often hobbled by bureaucracy and siloed thinking. MUSC’s commitment to innovation, a key part of the Imagine MUSC 2020 strategic plan, has helped overcome some of that inertia, Shah said. Especially helpful has been the Foundation for Research and Development, a non-profit organization meant to bridge the gap between business and science by commercializing new inventions created at the Medical University.

Shah has consulted with the FRD, and while he doesn’t know whether he will commercialize this application, he said the foundation offered important support along the way.

That support helped overcome the pushback of vendors who had spent years and millions of dollars developing their own proprietary systems. While he heard quite a few no’s initially, Shah said his data eventually spoke for itself. His work on the medication early warning system has now been successfully implemented, saving time, money and lives.   

Shah stressed the important role of entrepreneurial thinking in preventing medical errors, which he believes is often overlooked, and said he wants to see further innovation in the field of medication safety. “This is the new paradigm in an era where technology intersects complex processes and where people have to make critical decisions for patient care,” he said.

He is currently working to build a community of health care innovators at MUSC to inspire breakthroughs and accelerate the adoption of transformative new technologies. He hopes to release more information on that soon.