A Shocking Report Relating To Medication Errors

I was shocked to learn that medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually. While I knew that the error rate was fairly high, I certainly didn’t realize how bad it actually was. The Institute of Medicine, the nation’s most prestigious medical advisory organization, released a report, “Preventing Medication Errors,” on July 20th that revealed the magnitude of the problem. It’s estimated that as many as 7,000 persons die annually due to medication errors. Drug errors are so widespread that hospital patients should expect to suffer one every day they remain hospitalized, according to the report.

The report is the fourth in a series done by the Institute of Medicine that has called attention to the enormous health and financial burdens brought about by medical errors. You may recall that the first report, “To Err Is Human,” was released in 1999. While that report caused a sensation when it estimated that medical errors of all sorts led to as many as 98,000 deaths each year — more than was caused by highway accidents and breast cancer combined – unfortunately very few of the Institute’s recommendations from the report have been implemented.

The report contained a number of recommendations that will be fairly easy to do. For example, drug makers were told to package more pills in individual packages. The companies were also criticized for failing to disclose the results of all clinical trials involving their drugs. That’s a much broader problem and one that has been debated for a long time. An interesting aspect of the report concerned the common practice of drug companies providing free drug samples to doctors. The Institute recommended that the practice should be discouraged because in many cases the samples were poorly controlled.

At least a quarter of the errors are preventable, according to the report. The Institute of Medicine urged major steps be taken by the government, health providers and patients alike. Four of every five U.S. adults take at least one medication or dietary supplement every day. Interestingly, almost a third take at least five. The more a person uses, the greater their risk of bad interactions. This is especially true if multiple doctors prescribe different drugs without knowing what the person already takes. The following are some of the report’s major recommendations:

• All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines.

• The government should the speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible. Fewer than about 20% of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient’s records show use of another drug that can dangerously interact.

• Patients and their families must be aggressive in questioning doctors, nurses and pharmacists about medications. Get a list of each drug you’re prescribed, why and the dose from each doctor and pharmacy you use, and show it at every doctor visit. “Take active steps to make sure you know what you’re getting, and is it what you need,” said report co-author Dr. Wilson Pace of the University of Colorado.

• The nation should invest about $100 million annually on research into drug errors and how to prevent them. Among the most-needed studies is the impact of free drug samples, which often lack proper labeling, on medication safety.

• The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs, but often have incomplete information or are written in consumer-confusing jargon.

• The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems.

The Institute of Medicine is an independent organization chartered by Congress to advise the government on health matters. It’s a group with credibility and one that should carry weight with Congress and the healthcare industry. I don’t believe that most folks had any concept of how bad the medication error problem is. For that reason, this report should be given immediate distribution nationwide. Clearly, it must be taken seriously by all concerned and its recommendations implemented.

Source: Associated Press and New York Times