Clinical inertia: errors of omission in drug therapy.

Abstract

P harmacists are trained to be vigilant about identifying and correcting medication-related problems, including prescription errors, contraindications, and drug interactions, as well as managing adverse drug reactions. However, certain prescribing problems, particularly in chronic illness management, are often overlooked or have not received appropriate attention and contribute to failure to achieve treatment goals. The causes of these problems are often errors of omission and errors in prescribing a drug therapy of sufficient intensity. By classifying these therapeutic problems as errors, we can draw on the tools used in the error literature, such as root-cause analysis and failure-mode and effects analysis, to better understand and analyze them. We must first define what we mean by error. In the highly publicized Institute of Medicine report To Err Is Human: Building a Safer Health System, James Reason’s definition of an error was adopted: a “failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).” Our reference to the word “error” in this discussion refers to the above definition. An error of omission is “a failure to carry out the necessary steps in the performance of a task.” An example of an omission error would be for a physician to recognize a high AMANDA G. KENNEDY, PHARM.D., BCPS, is Research Assistant Professor of Medicine and CHARLES D. MACLEAN, M.D., is Associate Professor of Medicine, Division of General Internal Medicine, College of Medicine, University of Vermont, Burlington. Address correspondence to Dr. Kennedy at the Division of General Internal Medicine, College of Medicine, University of Vermont, 371 Pearl Street, Burlington, VT 05401 (amanda.kennedy@vtmednet.org). The following individuals participated in the root-cause analysis of diabetes and contributed to the authors’ understanding of clinical inertia: Anupam Goel, M.D., Dana Walrath, Ph.D., Alan S. Rubin, M.D., Dryver R. Huston, Ph.D., Benjamin Littenberg, M.D., Marilee C. Jones, M.A., Tracey Niquette, M.S., and Robert W. Beardall, M.D., M.P.H.