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Medication Errors Harming Millions, Report Says
Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine

By Marc Kaufman
Washington Post Staff Writer
Friday, July 21, 2006

At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications, the influential Institute of Medicine concluded in a major report released yesterday.

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 occupies a hospital bed, the report by a panel of experts said.

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 in response to a request made by Congress in 2003 when it passed the Medicare Modernization Act.

The report found errors to be not only harmful and widespread, but very costly as well. The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be $3.5 billion a year.

"Even I was surprised and shocked by how common and serious a problem this is," said panel member Albert Wu, a drug safety specialist at Johns Hopkins University. "Everyone in the health-care system has to wake up and take this more seriously."

Many of these medication errors could be avoided if doctors adopted electronic prescribing, if hospitals had a standardized bar-code system for checking and dispensing drugs, and if patients made more of an effort to know about the risks of the drugs they take, the report said.

The panel members said the problem requires immediate action and that many key players in health care have been slow to take the steps -- and invest the money -- needed to significantly reduce medication errors. At least a quarter of the injuries caused by drug errors are clearly preventable, the report said.

"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," panel member Charles B. Inlander said 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."

Common errors include doctors writing prescriptions that could interact dangerously with other drugs a patient is taking, nurses putting the wrong medication -- or the wrong dose -- in an intravenous drip and pharmacists dispensing 100-milligram pills rather than the prescribed 50-milligram dose.

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.

The study, funded by the Centers for Medicare and Medicaid Services, was assembled by 17 experts in related fields who analyzed research in the field, as well as government reports and data. They also held public forums to hear from representatives from the health-care system.

Panel co-chair J. Lyle Bootman, of the College of Pharmacy of the University of Arizona in Tucson, said there is enough research and data on medication errors to conclude that there is a major problem, but not enough to fully understand and address the issue. He said the nation should spend $100 million a year to research drug errors, especially among pediatric and psychiatric patients and in long-term care facilities, where medications are heavily used.

The report looks to new technologies in addition to electronic prescribing to dramatically reduce the number of medication errors. Hospitals, for instance, could greatly benefit by having a standardized bar-code system to ensure that a patient gets the correct medicine, it says. But drug companies and vendors have created six distinct systems requiring different bar-code readers, the report said, making them a far less useful safety tool for hospitals.

The report did not address 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 made clear that they believe the pharmaceutical industry and the FDA have not done enough to make drug information accessible to consumers and to make drug packaging as error-proof as it could be. The report said, for instance, that many medications would be better dispensed in blister packs that make it easier to identify them and for consumers to remember whether they have taken that day's dosage. It also said too many drugs have similar names that are easy to confuse.

In a statement, the FDA embraced the report and said it "provides a much needed perspective on the frequency, severity and preventable nature of medication errors." It said the recommendations "are supported by efforts already underway at FDA in the areas of medication error prevention, patient education and label comprehension."

The report endorsed much wider use of electronic prescribing. Inlander, president of the People's Medical Society, a Pennsylvania consumer health advocacy group, said chain pharmacies have been "ahead of the pack" in adopting such prescribing. The report said that all health-care providers should have plans in place by 2008 to move to electronic prescribing and dispensing, and that doctors should give up their traditional prescription pads by 2010.

Cecil B. Wilson, board chairman of the American Medical Association, also voiced support for "e-prescribing" and other information technology, but he said that "physicians face a dizzying array of choices when trying to purchase [the technology], while struggling with high costs, interoperability and ease of use."

Michael C. Tooke, chief medical officer of the Delmarva Foundation, which works on health-care quality in more than 30 states, said e-prescribing will bring a needed end to deciphering physicians' illegible handwriting but cannot guarantee that a drug order is typed correctly.

"E-prescribing is just going to allow us to make different errors and faster," he said. "It never just boils down to one thing."

The report's most striking findings concerned hospitals and long-term care facilities, which it said generally do not report errors 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 or not they cause harm.

Based on past 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 probably much higher.

Locally, more than four dozen Maryland hospitals take part in comprehensive annual surveys of their safety measures, including procedures for averting medication mistakes. Frederick Memorial Hospital has a particularly active medication safety program, which includes a computerized system to "reconcile" medications at numerous steps in a patient's stay.

The system has helped to quickly catch problems, including the omission of needed drugs, which clinical nurse specialist Susan Archer said "can make all the difference."

Staff writer Susan Levine contributed to this report.

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