Medication Errors

The Institute of Medicine recently released a report outlining the prevalence of medication errors in the United States. Dr. M. Zuhdi Jasser, president of the Arizona Medical Association provides information about prescription medication safety.

Transcript:

Michael Grant:
Tonight on "Horizon," Arizona's two biggest power providers have assured the public there will be plenty of electricity this summer to run air conditioners across the state. We check in with one of those utility providers. Plus, errors on prescription medications in the United States are outlined in a recent report by the institute of medicine. We talk about prescription drug safety concerns and some of the recommendations for preventing errors. Those stories next on "Horizon".

Announcer:
Horizon is made possible by contributions from the friends of 8. Members of your Arizona PBS station. Thank you.

Michael Grant:
Good evening. Welcome to Horizon. I'm Michael Grant.

Michael Grant:
Sweltering heat across the country is putting a major strain on electric utility providers in many regions. Here, although we are used to dealing with the heat, there are still challenges facing the companies that provide electric power. Utilities have to forecast of course, peak consumption periods, plan for emergencies and growth. The companies must also make sure all power plants and lines are working and generating equipment is operating sufficiently to handle the summer load. Here now to update us on SRP's summer power supply is Mike Hummel, manager of supply and trading for the Salt River Project.

Michael Grant:
Mike, thanks for being here.

Mike Hummel:
Thank you.

Michael Grant:
I'm going to take a shot in the dark here and say you guys probably set a new peak about two weeks ago?

Mike Hummel:
we did. A week ago last Friday we set a new peek. We set a new peak compared to the year before as well as a new peak compared to what our forecast was.

Michael Grant:
Was it on that day, mike, I think it hit 118 degrees?

Mike Hummel:
Yeah. We hit 118 degrees. That day we were at 117 and 116 the days preceding that. We did exceed the peek on the 118 day.

Michael Grant:
Was that not only a new peak for the system, was that also higher peak than what had had been projected say in the spring?

Mike Hummel:
yeah, we do our forecast almost a year before the summer. We start putting that forecast together in order to prepare our resources to be able to meet it. When we make a forecast, we set a base forecast and a range around that where we expected to come in. It exceeded the top end of that range that we forecasted. It was a very hot day and peak certainly reflected that.

Michael Grant:
A lot of different variables going into that. Obviously the main thing is a weather variable and since we sometimes have difficulties getting that correct say 24 hours out, I would think 365 would be a challenge. But it's got several other variables as well including but not limited to well, in which the growth in the valley both in numbers and also in electricity consumption.

Mike Hummel:
Well that's right, we look at numbers of new customers coming into the valley we look at average consumption per customer so we try to forecast how much each house will be using, and each residence and commercial installation will be using and it's extremely temperature dependent. That's probably the biggest driver of our peak is the temperature. During the summer when the temperature changes one degree, we can see an increase and a load of over 200 mega watts with just one degree change. It's very sensitive to that.

Michael Grant:
I realize anything is possible in most areas including but not limited to Arizona. But does the peak normally occur in the June/July time frame? Is it unlikely we will see another peak for the balance of the summer?

Mike Hummel:
It's more likely we see the peak in July. At the end of July, it's not a surprise to see it. We've seen the peak at other times as well. Hopefully we've been there and done that as well. Could it occur in August? It certainly could. August typically has a hard time getting above 115 degrees and then when you get into September 110 is typically as high as we're going to see. Like you say, anything is possible and we can see that.

Michael Grant:
Is that primarily a function of the increased humidity? Is that the reason or does that moderate the temperature some more?

Mike Hummel: We see increased humidity this time of year. The temperatures may be the same. It's more uncomfortable when the humidity's higher for those times of year. So you see people using their electricity differently, you see them running their air conditioners more and longer when it is more humid and more comfortable.

Michael Grant:
We've had a fairly good run of months in storms, unfortunately more wind than rain. What about the distribution system, has it been withstanding the gale force winds alright or not?

Mike Hummel:
Our transmission and distribution systems held up very well this summer. We have had a lot of winds. We had an incident a couple of weeks ago where we lost some 69kv, 69,000-volt poles less than 20 of those. If you go years past, we have a history and all utilities have a history of losing a lot more than that during the summer. We've had a number of preventative maintenance programs over the past 5/10 years that have helped that. We have put in pole stoppers we have done pole repair and pole maintenance and structural improvements as well as a lot of testing on our underground equipment. Transformers we test routinely infrared testing on our transformers to look for problems before they happen. We've done a lot of preventative maintenance and hopefully we're starting to see the benefits of that.

Michael Grant:
Did the situation at San Tan impact supply to any appreciable degree?

Mike Hummel:
It did not. The fire at San Tan was in the transformer in the receiving station which is a switch yard that connects San Tan to the rest of the electrical grid. That's where the fire occurred. It was not in the plant proper. We were able to switch around that transformer and redirect power from the plant. We didn't have any outages associated with it and we didn't expect any.

Michael Grant:
You know, there was great concern going into the summer for a variety of reasons including but not limited to electricity supply that this was going to be a terrible fire season because it was dry both in the high country and lower Elevations. I don't want to jinx us or anything, it looks like we may have dodged that bullet. There were some fires did that cause any transmission disruptions at all.

Mike Hummel:
Well, a little bit. We went into the summer like you said, believing that fires were probably our biggest exposure through the summer. As dry as the forest and desert was we felt that that could be an impact. We did have a fire up on the rim which caused us to shutdown one of the transmission lines for a few days. And that was mainly to be able to fight the fire. To allow the firefighters access to fight it as well to keep the line from reacting to the smoke that can get in the line. I don't want to say we're past it yet. It's a very dry forest. We've had some rain that's been helpful. Let's hope we get more. But I don't want to say we're past it yet. We have a long time to go before the summer is over. And we still look at that very carefully.

Michael Grant:
So there's really about three reasons you shutdown a transmission line.

Mike Hummel:
In the event of the fire we would shut it down if the fire impacts the line directly, if it's burning under the line, we think towers and lines structurally are in danger, we'll shut it down or operate it differently if we believe the smoke from the fire can impact the line. The fire can be half a mile away, but if the smoke is blowing into the line that can impact how that line operates and it can cause that line to trip or disconnect. So we try to avoid that. As much as that, we shut the lines down to allow firefighters to access the fire, to be able to fight the fire.

Michael Grant:
So they can safely move into wherever it's--

Mike Hummel:
Correct. Or they can operate their equipment safely within that area.

Michael Grant:
Obviously, we have heard about California's power difficulties the brownouts over there. Is that a generation supply problem or is it a distribution problem in the main?

Mike Hummel:
In some areas it's been distribution the LA area has had some distribution problems and they have had customers out of service not from generation-supply issues but from transformers and lines failing.

Michael Grant:
Basically heavy power more people using air conditioners for longer times?

Mike Hummel:
Correct. More load on the transformers, perhaps bigger houses. It's hard for me to say what caused that additional load but largely driven by the heat. So that part of it was out. California has their supply and demand is a little bit tighter for generation as well. So you see some of the warnings coming from the system operators at California about potential generation shortages. They have not had any forced outages as a result of the forced generation supplies as of this year.

Michael Grant:
Obviously, power moves back and forth between the two states but I would assume when SRP, APS and a variety of other people are at summer peak, there's probably not a lot of power you can send over to California.

Mike Hummel:
We will market power when we can. During our summer months our primary focus is keeping our lights on and making sure we have enough supply on any given hour and look for an opportunity to sell that and that revenue comes back and lowers our retail customer's rates. Typically our focus this time of year is our own supply and making sure we have enough.

Michael Grant:
You have to have it to sell it. Mike Hummel of SRP, thank you very much for the info.

Mike Hummel:
Thank you.

Michael Grant:
It is estimated that, in any given week, four out of every five US adults will use prescription medicines, over-the-counter drugs, or dietary supplements of some sort, and nearly one-third of adults will take five or more different medications. On occasion, mistakes can occur somewhere between the patient and the health care provider that cause a medication error. A recent report by the Institute Of Medicine called "preventing medication errors" looks at estimates of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies. In a moment we will talk about some of those strategies for preventing medication errors. First, Merry Lucero spoke with one valley doctor about her concerns regarding prescription errors and how she avoids them.

Merry Lucero:
It's not high-tech but it is an invaluable tool in this doctor's office. This handwritten color-coded chart lists medications by name and providers who cover them. It is the quickest way family practitioner Dr. Karla Birkholz makes sure patients get the right medication.

Karla Birkholz:
This is one way since we don't have the perfect system yet, computerized, that we try to manage complexities of different problems, different insurance companies or pharmacy benefit programs and which medications are preferred, third-tier which means higher co-pay or not covered at all.

Merry Lucero:
The maze of medication formularies is complex.

Karla Birkholz:
The estimate is over 30% of prescriptions have to be renegotiated once they get to the pharmacy so there has to be conversation about is this medication on the patient's formulary. Is the pharmacy benefit manager approving this amount of medication for this specific problem? Then a letter comes back and we have to justify that medication.

Merry Lucero:
Generics and abbreviations can be a challenge for doctors, pharmacists and patients to manage.

Karla Birkholz:
A lot of times when we talk to a patient, we talk about brand name. I might be lazy about it. The brand names are easier to pronounce and easier for the patients to remember them, so I'll discuss it. They go to the pharmacy and get a medication with a completely different name. So how do they connect that with the discussion that we had? If we had a discussion about Tenormin the whole time and they pick up a medication called Atenelnol, that's a problem. Or if they go to another physician's office and get a prescription there, they may be taking the Tenormin that I prescribed and then the other physician gives them a prescription for Atenelnol, the patient doesn't know that's the same medication and they are doubling up on the dose at that point.

Merry Lucero:
Dr. Birkholz looks forward to when this information is on line. In the meantime she is among the growing number of doctors who have purchased software systems to manage medical data on patients and their prescriptions.

Karla Birkholz:
If the patient can come to the doctor's office with an accurate list of what they're already on, weather they came from the hospital or their home, that's a good place to start. Then we have to sit there and talk about what's going on in their lives, what problem they're dealing with. I have to come up with the right solution for them, hopefully, and go to the stage of writing the next prescription.

Merry Lucero:
And with the computerized system, writing the prescription is a clear improvement.

Karla Birkholz:
Physician's understand. The reason I have an electronic medical record is because one of my physicians had terrible handwriting. It was a big problem for us because we had to constantly find out what the prescription said. The pharmacists would call us and the patients were confused. We got electronic records so we can read it. It's typed out on a piece of paper that is readable even if our signature isn't.

Merry Lucero:
But there are more than 300 vendors for physician software systems and bugs to work out before different systems will be cross referenced. In the meantime, the best advice is keep your own records, ask questions and communicate with your doctor.

Karla Birkholz:
Share with your doctor what you're doing with the medications. Are you taking it twice a day? Did you forget the second dose? You just don't buy it because it's too expensive? A lot of people don't want to admit that. Share those kinds of things. Taking over-the-counter medications are important, herbal kinds of things, vitamins. Then if you are confused, ask questions. If you are still confused when you go home from the doctor, give him a call or better yet come back and go over it again if there's been some problem.

Michael Grant:
Joining me now on more prescription drug errors and their prevention is Doctor M. Zuhdi Jasser, president of the Arizona Medical Association and Maureen Harris Dicker who was a network patient safety officer for the Department Of Veterans Affairs, now serves on the Arizona hospital and Healthcare Associations Patient's Safety Steering Committee and Patient Family Centered Care Advisory Group. Dr. Jasser could we solve all this if we had a mandatory first-year med school course on good handwriting techniques?

Dr. M. Zuhdi Jasser:
I wish it was that simple, Mike. The handwriting is certainly a problem and part of the printer errors which is looking at if you write QID which means four times a day or QD, and the difference is only the little "I" in the middle. So we're looking at conventions to try to improve that. But I can tell you as a primary care doctor, when I try and navigate and be the quarterback with my patients and care, there's nothing more intimidating than trying to figure out if the patient has the lists correct and every time they come in seeing which changes the 12 other specialists have done. I'm very interested in making sure we try to improve on this report. It's a symptom. It's a symptom of an underlying problem and malady in our healthcare system in that it's becoming more fractionated. The distance between me and my patients are increasing because of the third-party formularies that each are different that I'm trying to keep track as we saw.

Michael Grant:
Gate keeper concept and referral to sometimes several doctor specialists.

Dr. M. Zuhdi Jasser:
I'll see a patient if I'm lucky and see them every month or two and in-between those visits, they've seen four or five other doctors that are navigating their plans with their organ systems, and I look at it and the patient sometimes as the institute report said--have them be more of a partner. I think the error on the parental doctors in the 60s they gave medications without the names. We have come to the realization that patients need to be partners in following their medication lists.

Michael Grant:
You know, Maureen, let's shift to the hospital setting. It seems to me that many people who might be a partner with their doctor, certainly attentive to their own healthcare and what they are taking, those kinds of things, wouldn't necessarily take the same attitude if they're in a hospital setting from the standpoint you seem surrounded by all this medical infrastructure, caregivers those kinds of things, okay. I'll be in a coma and whatever it is I'm there for. Many have a different attitude towards that? Am I guessing right or not?

Maureen Harris Dicker:
I think what you're saying is true. It's a false sense of security, if you will. Every time a patient changes from one handoff to another, they are at risk for medication errors. A patient seen in LSU or emergency room or they might go to an intensive care unit and then to a floor, each time the patient goes to a different area, they are seen by a number of different specialists and medication is changed because in intensive care everything is intravenously. You go to the floor, it's a pill. There's a chance for double dosing if the IV isn't discontinued before the pill is started. It requires hyper vigilance and there's nothing like the patient asking questions and being a partner in their care to help us assure they get what they are supposed to get.

Michael Grant:
Obviously these problems have been with us for a while and are getting new attention. Is that at least in part because of this institute of medicine report that came out?

Maureen Harris Dicker:
I think so. I think there's a huge paradigm shift in healthcare. As you said before, it was a paternalistic view. The physician spoke, the patient listened. And now we're asking the patient tell us if you don't understand what we're saying because we're used to this medical terminology, ask us for pamphlets. A good thing a patient can do is bring a friend or family member when you go to the surgeon or you're being seen for a new diagnosis. You have someone else to hear it also and when you go home, there's someone to discuss it with and bounce ideas.

Michael Grant:
I would think it wouldn't be a bad idea in the office setting as well depending upon the nature and dragging somebody along every time, but on a consult on maybe a new medical situation or something in addition. It's always nice to have another set of eyes and ears and those kinds of things.

Dr. M. Zuhdi Jasser:
absolutely. You can't understate the value of repetition. I think the medical industry is finally starting to catch up a little bit. If you compare it to the airline industry, accounting, financial industry or legal, they have been going to the electronic systems that decreased the errors a long time ago. And I think a lot of that goes with the financial base. A lot of our costs are taken up through administrative issues and a lot of strains on the system preventing it from doing the frontline care. I think that's one of the things we can learn from the institute report. One, do what we can to decrease the errors. Two, maybe this is a sign of an underlying problem. How do we get more out of the system for the money we put into it? Because patients need to be able to learn and come to the visits and make sure that there are not errors that we are propagating. Like doing your taxes, your accountant can only be as good as the information you give him. Your doctor can only be as good as the symptoms you tell him or her and information you give him on your medications.

Michael Grant:
What about the record keeping and for that matter record transmittal aspect itself. How are doctor's offices both improving their own electronic way of keeping records as well as electronically sharing that. As you refer out to specialists not handing to the patient here's a copy of your file instead of electronically transmitting?

Dr. M. Zuhdi Jasser:
I think we've done better. In the last year, you've seen a blossoming of electronic medical record or EMR companies that are starting to compete to provide us with an electronic solution for our practices. E-prescribing where I write a prescription in the electronic system in the office and shows up at the pharmacy immediately. We are a half a step and a journey that's many, many miles because the systems are not integrated. The pharmacies themselves and between corporations, one pharmacy and another is not integrated. The cost--the problem is this is--you know, it's easy for the president for example to say that we had--we need to have EMR by 2010. It's unfunded. Where will it come from? Who will be able to save financially from decreasing duplicates of prescriptions from Making--we get the right drugs from the formulary, I believe it's the insurance companies and the pharmacies that are paying for it. I believe between the two of them on the state or national level we can accelerate the institutional electronic medical records.

Michael Grant:
From the hospital standpoint the same question. The electronic, the computer systems of hospitals lagging behind, catching up, moving ahead of curve? Where are we?

Maureen Harris Dicker:
Since we work for the department of veteran's affairs I answer from the perspective of that. We have a lot of electronic medical records. VA has had things like bar-coded wristbands for a number of years. What that allows the nurse to do at the bedside is scan a barcode on the medication as well as the patient's wristband to make sure it's the right patient, right medication, and right dose, and right time. Because it's connected to our electronic record, it helps us reduce errors. That's how we have all got ahead.

Michael Grant:
The report said that administration of the drug was a frequent cause. Is that just the patient not understanding, okay, here's how I take this drug? Here's how often I take this drug? You know, how long I take this drug?

Dr. M. Zuhdi Jasser:
It's amazing. One of things, you and I are healthy and everything's working fine, and we approach it from our own perspective. So many patients are elderly that have some cognitive impairment or patients that have so many other issues that sometimes understanding I may ask them--even if I ask them and ask the patient to repeat it back, an hour later they may not remember it correctly. That's where a lot of errors are. They go home and get the prescription. They can't remember which is for what, if it's for blood pressure or something else. You tell them to take it as needed or at a certain time for a reason and they can't remember that.

Michael Grant:
All right, doctor. Thank you very much for being here. Maureen, our thanks to you as well.

Nadine Arroyo:
Thousands of teens from all over the world will make their way to the valley for JCC Maccabi games. Promoting community involvement and teamwork and a program which allows students to come up with innovative ideas to solve real problems for people. That's Wednesday at 7:00.

Michael Grant:
For transcripts of "Horizon," and to find out more on upcoming topics, please visit our web site at azPBS.org. And next following "Horizon," stay tuned for "Arizona stories." among tonight's stories: Picacho Peak, the Wrigley Mansion, the Civilian Conservation Corps and the Riverside Ballroom. Thank you very much for joining us on this Tuesday edition of "Horizon." I'm Michael Grant. Have a great one. Good night.