Prescription Errors Kill, Injure Americans, Report SaysJul 20, 2006 | Washington Post At least 1.5 million Americans are sickened, injured and killed each year by avoidable errors in prescribing, dispensing and taking medications, the influential Institute of Medicine concludes in a major report released today.
Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she fills a hospital bed, the report says.
Following up on its influential 2000 report on medical errors of all kinds, the Institute, a branch of the National Academies, undertook the most extensive study ever of medication errors at the request of Congress when it passed the Medicare Modernization Act in 2003.
The report found errors to be not only harmful and widespread, but very costly as well. The extra medical costs of treating drug-related injuries occurring only in hospitals was estimated conservatively to be $3.5 billion a year.
"The frequency of medication errors and preventable adverse drug events is cause for serious concern," said Linda R. Cronenwett, dean of the University of North Carolina, Chapel Hill, School of Nursing and co-chair of the panel that researched the report. She and other panel members said that the problem requires immediate action.
"Everyone in the health care system knows this is a major problem, but there's been very little action and it's generally remained on the back burner," said panel member Charles Inlander, in an interview. "With this report, we hope to give everyone involved good, hard information on how they can prevent medication errors, and then create some pressure to have them implement it."
The errors studied by the Institute included doctors writing illegible prescriptions, nurses giving one patient medication intended for another, and a local pharmacist dispensing 100 milligrams pills rather than the prescribed 50 milligrams. The report spotlighted the case of Betsy Lehman, a 39-year-old health reporter for the Boston Globe who died in 1994 after being given an erroneously high dosage of an experimental chemotherapy agent. At least a quarter of the injuries caused by drug errors are preventable, the report said.
The report did not address the equally controversial question of whether some drugs should be pulled from the market because of their intrinsic risks or whether the Food and Drug Administration does an adequate job of ensuring that approved drugs are safe for general use. That is the subject of another Institute study expected to be released soon.
But the panel members did make clear that they believe the pharmaceutical industry and the FDA have not done enough to make information about individual drugs clear and easy for consumers to understand and caregivers to dispense. It also says that too many drugs have very similar names that are easy to confuse and that many medications would be better dispensed in blister packs that make it easier to identify them and easier for consumers to keep remember whether they've already taken that day's dosage.
The report endorsed much wider use of electronic prescribing, which it says reduces errors. Inlander, president of the People's Medical Society, a Pennsylvania consumer health advocacy group, said that chain pharmacies have been "ahead of the pack" in adopting electronic prescribing. The report asks all health care providers to have plans in place by 2008 to move to electronic prescription writing and receiving, and for doctors to give up their traditional prescription pads by 2010.
The report's most striking findings concerned errors in hospitals and long-term care facilities, which it said are generally not reported to patients or family members unless they result in injury or death. The panel said all health care organizations should report medication errors to patients whether they cause harm or not.
Based on existing studies, the panel estimated that drug errors cause at least 400,000 preventable injuries and deaths in hospitals each year, more than 800,000 in nursing homes and facilities for the elderly, and 530,000 among Medicare recipients treated in outpatient clinics. The report said the actual numbers are likely to be much higher.
Inlander said that the IOM panel sought information about how many people may have died as a result of drug errors, but said the estimates were so different ranging from 7,000 to 50,000 a year that they were not included in the report.
The report also addresses the issue of errors of "omission" medications that patients should be getting but do not. Panel co-chair J. Lyle Bootman, of the College of Pharmacy of the University of Arizona, Tucson, said yesterday that the panel believed those errors to be as widespread as other errors, but that researchers have not yet quantified the problem. Bootman said that the question of errors of omission is one of many that has to be aggressively researched so that corrective steps can be taken.