NEWS - Drug errors injure more than 1.5 million Americans every year

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Report: Drug Errors Injure More Than 1.5M

By LAURAN NEERGAARD, AP Medical Writer

Thursday, July 20, 2006

(07-20) 14:20 PDT WASHINGTON (AP) --

Medication mistakes injure well over 1.5 million Americans every year, a

toll too often unrecognized and unfought, says a sobering call to action.

At least a quarter of the errors are preventable, the Institute of Medicine

said Thursday in urging major steps by the government, health providers and

patients alike.

Topping the list: All prescriptions should be written electronically by

2010, a move one specialist called as crucial to safe care as X-ray

machines.

Perhaps the report's most stunning finding was that, on average, a

hospitalized patient is subject to at least one medication error per day.

A serious drug error can add more than $5,800 to the hospital bill of a

single patient. Assuming that hospitals commit 400,000 preventable drug

errors each year, that's $3.5 billion - not counting lost productivity and

other costs - from hospitals alone, the report concluded.

" I'm a patient-safety researcher (yet) I was surprised and shocked at just

how common and how serious a problem this is, " said Dr. Albert Wu of s

Hopkins University, who co-authored Thursday's report.

Worse, there's too little incentive for health providers to invest in

technology that could prevent some errors today, added Dr. J. Lyle Bootman,

the University of Arizona's pharmacy dean, who co-chaired the IOM probe.

" We're paid whether these errors occur or not, " lamented Bootman, who

recently experienced the threat firsthand as his son-in-law dodged some drug

near-misses while in intensive care in a reputable hospital.

The new probe couldn't say how many of the injuries are serious, or how many

victims die. A 1999 estimate put deaths, conservatively, at 7,000 a year.

Even the total injury estimate is conservative, Bootman stressed. It

includes drug errors in hospitals, nursing homes and among Medicare

outpatients, but it doesn't attempt to count mix-ups in most doctors'

offices or by patients themselves.

There have been efforts to improve patient safety in the six years since the

IOM first spotlighted medical mistakes of all kinds, including recent

bar-coding of drugs to minimize mix-ups in hospitals and pharmacies.

But clearly more are needed, and the new report highlights how the nation's

fragmented health care system is conducive to drug errors, said Dr.

Berwick, a Harvard professor who heads the nonprofit Institute for

Healthcare Improvement.

" This isn't a matter of doctors and nurses trying harder not to harm

people, " Berwick cautioned. " Safety isn't automatic. It has to be designed

into the system. "

Medications' sheer volume and complexity illustrate the difficulty. There

are more than 10,000 prescription drugs on the market, and 300,000

over-the-counter products. It's impossible to memorize their different usage

and dosage instructions, which may vary according to the patient's age,

weight and other risk factors, such as bad kidneys.

Plus, four of every five U.S. adults take at least one medication or dietary

supplement every day; almost a third take at least five. The more you use,

the greater your risk of bad interactions, especially if multiple doctors

prescribe different drugs without knowing what you already take.

Add doctors' notoriously bad handwriting and sound-alike drug names: Was

that order for 10 milligrams or 10 migrams? The hormone Premarin or the

antibiotic Primaxin?

Moreover, consumer instructions are woefully inadequate, the report

concludes. One study found parents gave their children the wrong dose of

over-the-counter fever medicines 47 percent of the time.

Then there was the newly diagnosed asthmatic wondering why his inhaler

didn't work. Asked how he used it, the middle-age man squirted two puffs

into the air and tried to breathe the mist. His original doctor had

demonstrated the inhaler without telling him to spray it inside his mouth.

Among the report's recommendations:

_The government should 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 percent of prescriptions are electronic, said report

co-author 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. 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.

http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2006/07/20/national/w142049D97.\

DTL & type=politics

Not an MD

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org