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Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually Report Offers Comprehensive Strategies for Reducing Drug-Related Mistakes
Washington, D.C. - infoZine
- Medication errors are among the most common medical errors, harming
at least 1.5 million people every year, says a new report from the
Institute of Medicine of the National Academies. The extra medical
costs of treating drug-related injuries occurring in hospitals alone
conservatively amount to $3.5 billion a year, and this estimate does
not take into account lost wages and productivity or additional health
care costs, the report says.
The committee that wrote the
report recommended a series of actions for patients, health care
organizations, government agencies, and pharmaceutical companies. The
recommendations include steps to increase communication and improve
interactions between health care professionals and patients, as well as
steps patients should take to protect themselves. The report also
recommends the creation of new, consumer-friendly information resources
through which patients can obtain objective, easy-to-understand drug
information. In addition, it calls for all prescriptions to be written
electronically by 2010 and suggests ways to improve the naming,
labeling, and packaging of drugs to reduce confusion and prevent errors.
"The frequency of medication errors and preventable adverse drug events
is cause for serious concern," said committee co-chair Linda R.
Cronenwett, dean and professor, School of Nursing, University of North
Carolina, Chapel Hill. "We need a comprehensive approach to reducing
these errors that involves not just health care organizations and
federal agencies, but the industry and consumers as well," she said.
Co-chair J. Lyle Bootman, dean and professor, College of Pharmacy,
University of Arizona, Tucson, added, "Our recommendations boil down to
ensuring that consumers are fully informed about how to take
medications safely and achieve the desired results, and that health
care providers have the tools and data necessary to prescribe,
dispense, and administer drugs as safely as possible and to monitor for
problems. The ultimate goal is to achieve the best care and outcomes
for patients each time they take a medication."
Estimates of Rates and Costs
Medication errors encompass all mistakes involving prescription drugs,
over-the-counter products, vitamins, minerals, or herbal supplements.
Errors are common at every stage, from prescription and administration
of a drug to monitoring of the patient's response, the committee found.
It estimated that on average, there is at least one medication error
per hospital patient per day, although error rates vary widely across
facilities. Not all errors lead to injury or death, but the number of
preventable injuries that do occur -- the committee estimated at least
1.5 million each year -- is sobering, the report says.
Studies
indicate that 400,000 preventable drug-related injuries occur each year
in hospitals. Another 800,000 occur in long-term care settings, and
roughly 530,000 occur just among Medicare recipients in outpatient
clinics. The committee noted that these are likely underestimates.
There is insufficient data to determine accurately all the costs
associated with medication errors. The conservative estimate of 400,000
preventable drug-related injuries in hospitals will result in at least
$3.5 billion in extra medical costs this year, the committee
calculated. A study of outpatient clinics found that medication-related
injuries there resulted in roughly $887 million in extra medical costs
in 2000 -- and the study looked only at injuries experienced by
Medicare recipients, a subset of clinic visitors. None of these figures
take into account lost wages and productivity or other costs.
Improving the Patient-Provider Partnership
Establishing and maintaining strong partnerships between health care
providers and patients is crucial to reducing medication errors, the
report says. The committee called on consumers to be active partners in
their medication care and on physicians, nurses, and pharmacists to
know and act on patients' medical care rights.
The report
recommends specific steps that physicians, nurses, pharmacists, and
other health professionals should take to ensure that their patients
are fully informed about their drug regimens and to minimize
opportunities for mistakes to occur. Health care organizations also
should make it a standard procedure to inform patients about clinically
significant medication errors made in their care, whether the mistakes
lead to harm or not. Currently, health care providers typically do not
inform the patient or the patient's guardians about errors unless
injury or death results.
The report also provides consumers
with a list of specific questions to ask health care providers, such as
how to take their medications properly and what to do if side effects
occur. Also included are actions consumers should take, such as
requesting that their providers give them a printed record of the drugs
they have been prescribed. Patients should maintain an up-to-date list
of all medications they use -- including over-the-counter products and
dietary supplements -- and share it with all their health care
providers. This list should also note the reasons they are taking each
product and any drug and food allergies they have.
New and Improved Drug Information Resources
Although consumers can find helpful drug information online or in the
printed materials provided by pharmacies, this information often is too
difficult for many people to understand, too scattered, or otherwise
not consumer-friendly. The quality of the drug information leaflets
that accompany prescriptions varies widely, and these printouts are
typically written at a college reading level. The U.S. Food and Drug
Administration (FDA) should work with other appropriate groups to
standardize the text and design of medication leaflets to ensure that
they are comprehensible and useful to all consumers.
The
committee called on the National Library of Medicine (NLM) to be the
chief agency responsible for online health resources for consumers; it
should create a Web site to serve as a centralized source of
comprehensive, objective, and easy-to-understand information about
drugs for consumers. In addition, NLM should work with other groups to
evaluate online health information and designate Web sites that provide
reliable information. The committee also recommended that NLM, FDA, and
the Centers for Medicare and Medicaid Services evaluate ways to build
and fund a national network of telephone helplines to assist people who
may not be able to access or understand printed medication information
because of illiteracy, language barriers, or other obstacles. This
telephone network should also enable consumers to report
medication-related mistakes or problems.
Electronic Prescribing and Other IT Solutions
New computerized systems for prescribing drugs and other applications
of information technology show promise for reducing the number of
drug-related mistakes, the report says. Studies indicate that
paper-based prescribing is associated with high error rates. Electronic
prescribing is safer because it eliminates problems with handwriting
legibility and, when combined with decision-support tools,
automatically alerts prescribers to possible interactions, allergies,
and other potential problems, the committee found. While it
acknowledged that significant regulatory issues and problems with
automated alerts still need to be worked out, the committee said that
by 2008 all health care providers should have plans in place to write
prescriptions electronically. By 2010 all providers should be using
e-prescribing systems and all pharmacies should be able to receive
prescriptions electronically. The Agency for Healthcare Research and
Quality (AHRQ) should take the lead in fostering improvements in IT
systems used in ordering, administering, and monitoring drugs.
All health care provider groups should be actively monitoring their
progress in improving medication safety, the committee recommended.
Monitoring efforts might include computer systems that detect
medication-related problems and periodic audits of prescriptions filled
in community pharmacies.
Drug Naming, Labeling, and Packaging
Confusion caused by similar drug names accounts for up to 25 percent of
all errors reported to the Medication Error Reporting Program operated
cooperatively by U.S. Pharmacopeia (USP) and the Institute for Safe
Medication Practices (ISMP). In addition, labeling and packaging issues
were cited as the cause of 33 percent of errors, including 30 percent
of fatalities, reported to the program. Drug naming terms should be
standardized as much as possible, and all companies should be required
to use the standardized terms, the report urges. FDA, AHRQ, and the
pharmaceutical industry should collaborate with USP, ISMP, and other
appropriate organizations to develop a plan to address the problems
associated with drug naming, labeling, and packaging by the end of 2007.
The report also recommends studies to evaluate the impact of free drug
samples on overall medication safety. In general, there has been
growing unease among health care providers and others about the way
free samples are distributed and the resulting lack of documentation of
medication use, as well as the bypassing of drug-interaction checks and
counseling that are integral parts of the standard prescription process.
The study was sponsored by the U.S. Department of Health and Human
Services and Centers for Medicare and Medicaid Services. Established in
1970 under the charter of the National Academy of Sciences, the
Institute of Medicine provides independent, objective, evidence-based
advice to policymakers, health professionals, the private sector, and
the public. A committee roster follows.
Pre-publication copies
of Preventing Medication Errors are available from the National
Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet
at www.nap.edu
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