1.5 million Americans a year affected by medication errors

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Roman Bystrianyk - 24 Jul 2006 03:49 GMT

"1.5 million Americans a year affected by medication errors", Seattle
Times, July 21, 2006,
Link:
http://seattletimes.nwsource.com/html/nationworld/2003141881_drugerrors21.html

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

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 2000 report on medical errors of all kinds, the
institute, a branch of the National Academy of Sciences, 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
costly as well. The extra medical cost of treating drug-related
injuries occurring only in hospitals was estimated to be at least $3.5
billion a year.

"The frequency of medication errors and preventable adverse drug events
is cause for serious concern," said Linda Cronenwett, dean of the
School of Nursing at the University of North Carolina at Chapel Hill,
and co-chair of the panel that researched the report. She and other
panel members said 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," panel member Charles Inlander said. "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 report endorsed much wider use of electronic prescribing, which it
says reduces errors, and encouraged technology improvements so the many
computer programs used by doctors, hospitals and drugstores are
compatible.

The errors the institute studied included doctors writing illegible
prescriptions, nurses giving one patient medication intended for
another, and a local pharmacist dispensing 100-milligram pills rather
than the prescribed 50 milligrams.

The report spotlighted the case of Betsy Lehman, a health reporter for
The Boston Globe. The 39-year-old wife and mother of two was being
treated for breast cancer in an experimental program at the Dana-Farber
Cancer Institute in 1994.

A medical fellow wrote a prescription for the cancer drugs citing the
total amount she was to receive over four days, the report said. She
died when nurses administered that total each day, overwhelming her
system. The hospital had no system in place to monitor dosages, and her
family argued that staff did not pay attention to her complaints about
the effects of the overdose, according to the report.

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 study expected to
be released soon by the institute.

With more than 4 billion prescriptions written each year in the United
States, even a very small error rate can translate into a large number
of problems.

Among the drugs most commonly associated with errors in hospitals are
insulin, morphine, potassium chloride and the anticoagulants heparin
and warfarin, which have a high risk of patient injury when dispensed
incorrectly.

The report cited a 2002 study from the United States Pharmacopeia that
found that these five drugs accounted for 28 percent of all errors that
resulted in extended hospitalizations. Insulin alone accounted for a
third of that total.

The panel cited a variety of causes for the problems.

One is unexpected drug interactions. With more than 15,000 prescription
drugs in use and 300,000 over-the-counter products, "it is virtually
impossible for a human to track all the interactions anymore," said Dr.
Wilson Pace of the University of Colorado.

Another is the similarity between drug names, which often results in
the wrong drug being given. For example, Fosamax, the osteoporosis
drug, could be mistaken for Flomax, given to improve urination in
patients with an enlarged prostate.

Other problems include patients not understanding how to take the
drugs.

The report said errors in hospitals and long-term-care facilities
generally are 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 much higher.

Inlander, president of the People's Medical Society, a Pennsylvania
consumer-health advocacy group, said that the institute panel sought
information about how many people may have died as a result of drug
errors, but that the estimates were so different - from 7,000 to
50,000 a year - that they were not included in the report.