Report: Drug Errors Injure 1.5 Million

The Average Hospital Patient Is Subjected to
at Least 1 Medication Mistake a Day

By Todd Zwillich
WebMD Medical News

Reviewed By Louise Chang, MD
on Thursday, July 20, 2006


July 20, 2006 -- About 1.5 million Americans are injured each year because of errors in their medications, an Institute of Medicine (IOM) report concluded Thursday.

The report estimates that such errors in hospitals alone cost the health system well over $3.5 billion per year. That does not include errors made at doctors' offices, pharmacies, long-term care facilities, and in patients' own homes.

The report says on average a hospital patient is subjected to at least one medication error per day.

Experts said that dangerous interactions between drugs probably account for the majority of medication mistakes. But errors and misinterpretations occur at any of dozens of points between a drug's manufacture and when a patient receives treatment.

Preventable Errors

"Many of these errors are preventable," said J. Lyle Bootman, PhD, who chaired the panel issuing the report.

The report calls on Congress to drastically boost funding for research into the causes of medication errors, noting that only a few million dollars annually are spent on studies now. A 1999 Institute of Medicine report estimated that more than 7,000 Americans are killed by medication mistakes each year.

"We think that medication errors deserve a really serious commitment. We need to rethink our priorities," said Albert W. Wu, MD, an IOM panel member who is also professor of health policy at Johns Hopkins University in Baltimore, Md.

U.S. doctors now prescribe more than 14,000 drugs, not including the huge range of over-the-counter medications, supplements, and herbal remedies in many Americans' medicine cabinets. The report called for policy makers to speed the development of electronic systems to help catch prescribing mistakes and alert doctors to potential drug interactions.

"It's virtually impossible to be able to track that any more by yourself," Wilson D. Pace, MD, a professor of family medicine at the University of Colorado and a panel member, said of the number of drugs on the U.S. market.

Even well-informed physicians and pharmacists face hurdles when ordering drugs. The FDA is trying to cut down on drug names that sound or look alike. Pharmacists still have to contend with notoriously bad doctors' handwriting, and patients frequently don't inform their doctors about all the drugs they're taking.

More Active Patients

The Institute of Medicine advises Congress on science and health care, and often does so at a level of bureaucratic detail beyond the interest of most members of the public. But experts Thursday appealed directly to consumers to help cut down on medication errors by actively tracking their medications and other treatments. They urged patients to maintain lists of all treatments and to become active in double-checking medications at the pharmacy and at home.

The report also urges patients to:
Have the provider explain how to use medications properly.
Get in writing, the name, dosage, purpose, and directions for taking each drug.
Maintain a list of all drugs and other over-the-counter treatments and take it along for every doctor visit.
Discuss side effects.
Discuss drug interactions with other drugs, foods, and diseases. "There's no way a provider can get them into their system without you telling them about it," Pace said. "If you can, become a more active member of the health care team. If you aren't sure of something, ask," Wu said.

Sound-Alike Names

The FDA recently moved to make drug safety labels more consumer-friendly. Only one drug has so far included the new label in packaging, according to the agency. The FDA is also preparing to issue guidance for the drug industry on how to avoid look-alike, sound-alike names that can confuse patients and health providers.

"We're trying to get companies to seriously think about the names before they submit them to us," Carol Holquist, director of the agency's division of medication errors, tells WebMD. The report also calls on all physicians to use electronic prescribing systems by 2010. While some hospitals and pharmacies are moving to electronic prescribing, small doctors' offices have been slower to use the technology because of cost. Wu acknowledged that some doctors may chafe at being asked to provide written descriptions on every drug they prescribe to patients."We'll get used to it," he said.

SOURCES: "Preventing Medication Errors," Institute of Medicine, July 20, 2006. Lyle Bootman, PhD, dean, University of Arizona College of Pharmacy; chair, Institute of Medicine panel. Wilson D. Pace, MD, professor of family medicine, University of Colorado. Albert W. Wu, professor of health policy, Johns Hopkins University, Baltimore, Md. Carol Holquist, director, FDA Division of Medication Errors and Technical Support.