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Jewish World Review March 15, 2005 / 4 Adar II, 5765
By Robert A. Wascher, M.D., F.A.C.S.
http://www.NewsAndOpinion.com |
Several previous studies have suggested that medication errors within hospitals are more common than most of us would like to think. While it is difficult to determine exactly how many patients are being harmed, or who die, as a result of such medication mix-ups, most experts believe that medication errors are a serious healthcare problem. Indeed, a comprehensive study by the prestigious Institute of Medicine estimated that more than 7,000 patients died in US hospitals in 1993 as a result of medication errors.
Approximately two-thirds of all medication errors are the result of physician prescribing error, while the remaining errors are due to nurse or pharmacist error, according to several studies. Overall, the Institute of Medicine estimates that about 2 percent of the patients who are admitted to a hospital each year in the US will experience some adverse event after receiving medications. Although most of these adverse drug reactions occur in patients in the absence of any medication errors, many such reactions arise after patients receive the wrong drug, the wrong dosage of the correct drug, or a drug that the patient was known to be allergic to.
Hospitals and healthcare personnel work very hard to eliminate medication errors, although the potential for human error ensures that this goal can never be fully achieved. Elaborate safeguards to check and cross-check all medication orders are standard in most hospitals. The majority of hospitals in the US are also adopting electronic medical record systems and computer-based physician order entry systems, in an effort to catch the inevitable human errors involved in prescribing and dispensing medications before patients actually receive any erroneous or inappropriate medications. Two newly published studies suggest that, despite all of the emphasis currently being placed on reducing or eliminating medication errors, we still have room for considerable improvement.
Archives of Internal Medicine: A new study prospectively evaluated patients being admitted to the hospital from Internal Medicine clinics. Four commonly prescribed medications were tracked as the internists admitted their patients to the hospital. This study was considered to be especially important, because the admission orders for these patients were written in the doctors' offices and, hence, prescribing errors could not be detected by the computerized order entry systems in place at most hospitals.
A total of 523 admissions for 151 patients were screened and analyzed. Incredibly, 81 of the 151 patients (54 percent) experienced at least one unintended medication order discrepancy. (The most common error on patient admission orders, occurring in 46 percent of the cases, was the omission of regularly used outpatient medications.) Although 61 percent of the medication errors were judged to have likely been harmless to patients, the remaining 39 percent of discrepancies were assessed as having presented moderate-to-severe risks to patients during their hospital stays.
This study found that medication errors, including a physician's failure to continue necessary outpatient medications while patients were hospitalized, occurred in more than half of all patient admissions to the hospital. These results indicate that medication errors, particularly among patients who are admitted to hospitals from their doctors' offices, are extremely common, and present significant potential for adverse outcomes. Clearly, more needs to be done to protect patients in this setting from illness or injury due to medication errors.
Journal of the American Medical Association: A second new study looks at the impact of hospital computerized order entry systems on medication errors. Previous studies have suggested that such systems can reduce medication errors by more than 80 percent, by alerting the doctor or the pharmacy about errors in medication orders. In this study, 261 physicians-in-training were surveyed between 2002 and 2004 at a major teaching hospital. Additionally, focus groups and one-on-one interviews were conducted with hospital Information Technology staff, pharmacists, senior physicians and nurses.
Interestingly, the computerized order entry system was actually found to facilitate multiple types of medication errors. The majority of these errors appeared to result from the fragmented or abbreviated display information presented on the order entry system's video screens. Specifically, physicians using this system had difficulty in achieving a coherent overview of patient medications, and they commonly mistook pharmacy inventory information as medication dosage guidelines. Other medication errors associated with limitations in the computerized order entry system's interface included unheeded antibiotic renewal notices, separation of order entry functions that increased the likelihood of double-dosing and the ordering of incompatible medications, and inflexible order entry formats that, quite simply, generated erroneous medication orders. These system-related errors were directly observed by study teams who monitored physicians as they ordered medications on the computerized order entry system. When the intern and resident physicians were surveyed by the researchers, three-fourths of the doctors reported observing each of these medication error types on a weekly basis, or more frequently.
While previous research has focused on the ability of computer-based order entry systems to reduce medication errors, this study is the first to focus on medication errors resulting directly from the use of such systems. In this case, a leading computerized physician order entry system was found to actually facilitate 22 specific types of medication error risks. Of note, the majority of physicians using these order entry systems in major teaching hospitals are young physicians who are being trained in their chosen specialties. Generally speaking, these interns and residents are, if anything, likely to me more adept at interfacing with computer-based systems than older attending physicians. One, therefore, has to wonder about the error rates generated by older attending physicians at hospitals that are not major teaching centers as they enter patient orders into computer-based order entry systems.
The primary value of this research study is that it points out significant weaknesses in at least one of the leading computer-based order entry systems. In doing so, this study focuses attention on critical areas where these now ubiquitous order entry systems need to be reevaluated and, potentially, upgraded.
SMOKING CAUSES GENETIC DAMAGE TO FETUSES
Among the smokers, 12 percent of the fetal cells revealed significant structural abnormalities, as compared to 3.5 percent in the non-smoker group. Even more concerning, the most common genetic abnormality noted in fetal cells taken from smoking mothers was a specific abnormality, in chromosome 11, that is associated with leukemia and other cancers of the bone marrow and blood.
The results of this study add further evidence that smoking hurts not only the smoker and the smoker's family members and companions (through secondhand smoke exposure) but, most unfortunately, the smoker's unborn baby as well. If you smoke, please stop. If you are pregnant and smoke, please stop now.
VITAMIN E AND PROSTATE CANCER RISK
The role of Vitamin E, and other antioxidant vitamins, in disease prevention has never been less clear. It has long been hypothesized that Vitamin E, by virtue of its antioxidant properties, should be able to prevent certain types of cell damage that have been linked to the development of cancer and cardiovascular disease, as well as other diseases associated with aging. This hypothesis is based upon our knowledge of cellular metabolism. A byproduct of our cells' metabolism is the generation of highly reactive species of chemical compounds known as free radicals. Scientists know that these free radicals are capable of damaging the DNA of our cells, and that this genetic damage can presage the development of life-threatening diseases. Unfortunately, large-scale epidemiological studies looking at antioxidant vitamins, including Vitamin E, have often failed to consistently reveal any health benefits associated with their consumption. Indeed, a recent study, which I reported on, actually suggested that high doses of Vitamin E supplements may actually be harmful. Adding to the generalized confusion about the role of vitamins and other antioxidant supplements in human health is the largely unregulated supplements industry. As I have previously mentioned, this industry, unlike the prescription drug industry, does not have to provide any scientific data supporting the efficacy or safety of its products before bringing them to market.
Another shortcoming of much of the published research on dietary supplements, including many vitamin studies, is the methodology of such studies. The majority of these studies rely upon surveys and questionnaires to gather their data and, therefore, there can be a considerable amount of subjectivity involved. This new study of Vitamin E's effects on prostate cancer risk side-steps the subjectivity of survey-based vitamin studies, in that its conclusions are based upon measured blood levels of Vitamin E, and not upon the recollections of Vitamin E intake by study subjects.
Journal of the National Cancer Institute: A previous study of more than 29,000 Finnish men, the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study, suggested that daily Vitamin E supplementation (in the form of alpha-tocopherol) reduced the risk of prostate cancer by as much 32 percent. In this new study, blood Vitamin E levels were measured in 100 ATBC Study men who developed prostate cancer, and 200 additional men from the Study who did not develop prostate cancer. The blood levels of two different forms of Vitamin E, alpha-tocopherol and gamma-tocopherol, were then correlated with prostate cancer risk.
In this study, men with the highest blood levels of alpha-tocopherol experienced a 51 percent reduction in the relative risk of prostate cancer, while the highest blood levels of gamma-tocopherol correlated with a 43 percent reduction in the relative risk of prostate cancer (consistent with the results of the much larger ATBC Study).
While the true benefits and risks of Vitamin E supplementation are still unclear, this study from Finland supports previous studies suggesting that Vitamin E supplementation may, indeed, reduce the risk of prostate cancer. Currently, the very large Selenium and Vitamin E Cancer Prevention Trial (SELECT) is following more than 32,000 men in North America. This prospective, randomized, double-blinded long-term study should provide definitive data on the impact of selenium and Vitamin E supplementation on prostate cancer risk. Meanwhile, this new Finnish study, in addition to the previously published ATBC Study, strongly suggests that Vitamin E supplementation can, indeed, reduce the risk of prostate cancer. Whether or not the overall benefits and risks of Vitamin E supplementation favor its routine use as a supplement will, unfortunately, have to await further large-scale studies. Meanwhile, a healthy and balanced diet, along with regular exercise, are prudent measures for maintaining good cardiovascular health, and for reducing overall cancer risks.
JWR contributor Dr. Robert Wascher is an oncologic surgeon, professor of surgery, oncology research scientist, and author. He lives in Honolulu with his wife and two daughters.
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Hospital medication errors; smoking causes genetic damage to fetuses; Vitamin E and prostate cancer risk
We know that smoking causes significant damage to the genes of cells in smokers' respiratory tracts and, indeed, throughout their bodies. These genetic changes accumulate over time in chronic smokers, and have been linked to the onset of cancer, lung injury, heart disease, vascular disease, stroke and other smoking-associated disorders. Very little research has been done, however, on the impact of smoking on the genetic well-being of fetuses. Now, a newly published study suggests that smoking during pregnancy damages the genes of the fetus, as well as the mother's genes.
Journal of the American Medical Association : Fetal cells floating in amniotic fluid were obtained during routine amniocentesis in 50 women. Half of these women were nonsmokers, and the other 25 women were current smokers who had smoked at least half-a-pack of cigarettes per day for at least 10 years. The two groups of women were balanced according to age and other health factors. The fetal cells were then analyzed by genetic experts who were blinded as to which group each woman was in.
More than 200,000 men will be diagnosed with prostate cancer in the US this year, and between 30,000 and 40,000 men will die from this disease. Within the US, African American men face the highest risk of prostate cancer among all ethnic groups.
