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
Between errors and bill padding, fighting a hospital overcharge or denied medical claim can take some smart strategies.
Fortune Magazine
By Ellen McGirt with Kate Ashford, George Mannes and Pat Regnier, MONEY Magazine
February 9, 2006: 10:31 AM EST
NEW YORK (MONEY Magazine) - Consider, just for a moment, the swirl of the modern health-care system. One wrong keystroke by a hospital administrator can land you in red tape hell.
That's enraging -- and scary.
"Would you believe a thousand-dollar toothbrush?" says Nora Johnson, a medical-billing auditor who has seen that and a lot of other absurdities. "More than 90 percent of the bills I review are either wrong or padded beyond belief."
Her own husband was once charged for blood tests for a newborn as part of his hip-replacement surgery. ("I was pretty sure he hadn't had a baby.")
If billing errors result in overcharging or, worse, a denied claim, understanding the bureaucracy -- the very thing that drives you nuts -- is your best offense.
How to fight back:
1. Know the codes
Your bill will be awash with medical shorthand for the treatment you received. There are two kinds of codes:
* Diagnostic codes (a.k.a. ICD-9 codes), which identify what was wrong with you
* Procedure codes (a.k.a. CPT codes), which describe what treatment you received
Coding problems can be the result of either blatant padding (one procedure to remove tonsils and adenoids is "unbundled" and billed as two separate procedures) or keystroke errors (one typo causes a mismatch between the ICD-9 and the CPT codes, and your claim is branded a "coding error" and rejected). If your claim bounces back or the bill seems high, ask the hospital or doctor for a thorough explanation of each and every code.
2. Be more prepared than they are
Everyone knows you're supposed to hang on to bills, but here's something most people miss: doctor's orders. Every time your physician prescribes something -- blood tests, X-rays, medication -- it's recorded in her standing orders.
You have a right to this stuff, so request a copy from the billing office. Keep it in a personal medical file, which should also include the following documents:
* Reports by any technician handling a procedure, as well as the nurses who administer medication or shuttle you around in your paper gown
* Itemized bills (request these from your doctors or hospital, possibly after your treatment visit)
* Your insurance paperwork
* Your own notes from each doctor visit
3. Demand relief by certified mail
Send (certified) a detailed letter to your doctor's office or hospital requesting a corrected bill. Then send (certified) another, equally detailed letter describing the problem, including your documentation, to the insurer. Don't forget copies of the doctor's orders and the bill.
If the doctor did order a test or procedure but the orders weren't carried out, you'll need documentation proving that. (Paperwork, as you may have surmised, is pretty much your lifeblood here.) Most insurers have a time limit, typically 30 or 60 days, within which they'll consider routine appeals. So get a move on.
(AP) When Chuck O'Brien visits his doctor, they talk about his aches and pains, his heart problems and his diet, but never about his health insurance.
That's because his doctor only accepts cash.
Dr. Vern Cherewatenko is one of a small but growing number of physicians across the country who are dumping complicated insurance contracts in favor of simple cash payments.
When O'Brien leaves the exam room, he writes a check for $50 and he's done — no forms, no ID numbers, no copayments.
"This is traditional medicine. This is what America was like 30 years ago," said O'Brien, 55 and self-employed, who believes he has saved thousands of dollars by dropping his expensive insurance policy and paying cash. "It's a whole world of difference."
Is this the health care wave of the future? Probably not, experts say. Most people are content with monthly premiums and $10 copays; nine out of 10 doctors contract with managed-care companies.
For the 43 million Americans who lack health insurance, cash-only is a fact of life when a trip to the doctor or the pharmacy cannot be avoided.
Even when treating patients who are insured, some doctors - frustrated by red tape at the insurance companies - view cash-only medicine as an increasingly attractive way to run their businesses.
"It's a terrible indictment of the collapsing health care system," said Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania Medical School. "Insurance and managed care were supposed to streamline - instead what they've done is add so much paperwork and bureaucracy they're driving some doctors out."
Health insurers downplay the trend, while emphasizing recent efforts to mend tattered relationships between doctors and managed care companies.
"I don't look at it as a threat," said Mohit Ghose, spokesman for the industry group America's Health Insurance Plans. "It's just a different way of practicing."
Medical establishment leaders don't object to doctors working for simple cash.
"This is America. One size does not fit all," said Dr. John C. Nelson, president-elect of the American Medical Association. "We certainly support the physicians' right to do that."
An obstetrician-gynecologist in Salt Lake City, Nelson easily recalled times when he believed managed care rules prevented his patients from getting the best treatment. He said cash-only doctors are driven by the desire to practice medicine without interference.
"There is a great intrusion by third parties into the patient-physician relationship," Nelson said. "We can understand their frustration."
Cherewatenko, a broad-shouldered 45-year-old who wears black jackets and red stethoscopes at work, switched to cash out of desperation six years ago. His suburban Seattle practice was hemorrhaging money, and he and his partners realized they were spending hundreds of thousands of dollars just to process insurance paperwork.
"We said, 'Let's cut out this administrative waste,"' Cherewatenko said. Before, he charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50 — and he never worries about collection costs, because patients pay in full after every visit.
Cherewatenko sees fewer patients now. His whole office would probably fit inside his old waiting room. But he says the freedom is worth it.
"Accounts receivable is zero. It's a great feeling," Cherewatenko said. "I feel like I'm a real doctor again."
He started a group called SimpleCare to spread the gospel of cash-only medicine. The organization steers patients to doctors who offer cash discounts, and gives technical and moral support to doctors who want to start cutting their ties to insurance. Membership has grown to 22,000 patient members and 1,500 doctors. Some reject all insurance and take only cash, while others continue to accept insurance while offering discounts of 15 percent to 50 percent for cash-paying patients.
Independent of SimpleCare, doctors in California, Colorado, Minnesota, Texas, Mississippi and other states have also quit the insurance game. Some tired of the paperwork and administrative expenses. Some wanted to spend more time with patients without managed care bean-counters peering over their shoulders. The patients who pay cash range from poor to wealthy, with most in the blue-collar middle.
"When I first started, I thought it would be the elite. That's not the case," said Dr. Shelley Giebel, an obstetrician-gynecologist in Temple, Texas, who washed her hands of insurance eight years ago.
Her standard, hour-long annual checkup costs $140. Everyone pays cash.
If a patient needs extra tests or treatment, Giebel tells them upfront what it will cost.
"If it is an urgent test, we'll go ahead and do it. We're not going to delay medical care because they don't have the money in hand," she said. Often, patients return later with the money.
"It has usually not been a problem that people forgo medical care," she said.
The cash-only movement isn't just changing the way people pay, it's changing the way these doctors work. Because of managed care's low reimbursement rates, doctors on insurance contracts must limit their time with each patient.
Giebel, a typical example, said she would have to double her patient load to make ends meet if she relied on insurance — something she can't imagine. "How can you possibly talk about prevention of cancer and heart disease when you're seeing patients every 12 minutes?" she asked.
Cash-only patients rave about the quality of care.
"They take time here with you," said Jesse Rainwater, a 59-year-old church pastor from Bellevue, Wash., who credits Cherewatenko with teaching him to manage his diabetes. "They don't just bring you in and run you out like a bunch of cattle. You feel like you're loved."
The cash-only approach evokes Norman Rockwell-tinged visions of country doctors being paid with chickens. The simplicity is tempting, but the truth is many people went without preventive health care in those "good old days." A $50 charge can be powerful incentive to delay seeing a doctor until you're in pain — which can lead to more expensive health problems later.
"Medicine used to be a cash-only business, and there were certainly many people who didn't have the cash," said Caplan, the medical ethicist. Doctors who insist on cash also have an ethical obligation to help people who can't afford the fee, he said — even if it means accepting chickens.
Cash crusaders acknowledge the need for some type of insurance. Without it, expensive surgery or hospitalization would force most people into bankruptcy. But they think health insurance should work more like car insurance: you pay for the routine maintenance and little dings yourself, and insurance pays for more expensive repairs.
O'Brien, a freelance marketing specialist, switched from a comprehensive health plan with $300 monthly premiums to a catastrophic plan that costs $75 a month, with a $2,000 deductible. He pays out-of-pocket for routine checkups, and his insurance will kick in if he ever needs expensive care.
The promise of a simple cash payment lured him to Cherewatenko's office, but the doctor's personal attention keeps him coming back. The $50 exams are just part of the bargain for O'Brien. Cherewatenko recently met him for coffee to talk about improving his diet — including an admonition to cut back on caffeine.
"How often does your doctor go out and have a cup of coffee with you?" O'Brien asked.
Are you looking for a cure for what ails you? According to a recent survey, almost 80 percent of Internet users search for health or medical information.
There are millions of sites offering advice on everything from treating abrasions to getting rid of warts. Unfortunately, erroneous advice is rampant, and some of it is tailored specifically to sway consumers toward a particular product.
"The problem with the Internet is there is good information and bad information, and to the uneducated eye, it's hard to tell the difference," says Dr. Alan Keck, president of the Florida Psychological Association. The Web is a good venue for unlicensed practitioners and, "of course, nobody regulates the Internet."
Keck recommends asking your health-care professional for advice on where to find information pertinent to your illness or condition. If you choose to pursue information on your own, though, "look for something that's an official site of an organized group of professionals, as opposed to a 'Dr. Schmooze I-Know-Everything' Web site."
The sites of licensed health-care professionals frequently link to such areas, which often have suffixes of .gov and .org, Keck says. For instance, the National Mental Health Association's Web site, nmha.org, provides online fact sheets that describe such things as anxiety disorders as well as advice on finding treatment. The Centers for Disease Control's site, www.cdc.gov, offers a wealth of information on such topics as diseases, obesity, workplace safety, vaccines and birth defects.
Consumers should carefully scrutinize the sources and evidence behind medical advice on the Web, says Leigh McKinney, director of online publishing for the American Academy of Family Physicians. "And always, always talk to a physician about what you read online before you make some change, start a new diet or [take] an herbal remedy," she says.
One page on the AAFP site, family doctor.org/783.xml, lists questions to ask about information found on the Web, including: Where did this information come from?, and, how current is it? The organization's home page (familydoctor.org) guides users to advice on such topics as flu shots, smoking cessation and pregnancy, as well as primers on insurance and choosing a general practitioner.
Many area and well-known national hospitals, universities and medical schools also have Web sites on which useful information can be found. For instance, at Mayo Clinic's Web site (mayoclinic.com), consumers can read about drugs, supplements, dental care and living healthily. Shands Health Care (shands.org/health), affiliated with the University of Florida in Gainesville, offers guidance on surgical procedures and the Health Illustrated Encyclopedia -- an A to Z guide to injuries, disease, nutrition and symptoms.
1. Keep Taxes Current. Rule number one for the owner of any struggling business is to meticulously pay all payroll taxes on time, especially those withheld from employees’ paychecks. Even if you operate your business as a corporation or LLC, the IRS and state tax authorities can hold you personally liable for these taxes plus penalties if they’re not paid. And even if the business goes bankrupt, you are still personally and legally on the hook to pay them.
2. Stave Off Cash Flow Problems. When you realize you don’t have enough revenue to pay the bills coming, slow your “burn rate” immediately by cutting expenses to the bone. Then prepare a short-term cash projection and plan for your immediate needs. Make a list of the monies owed to you, and collect as much of it as possible. Pay the necessary items like taxes and overhead costs, but delay paying other bills by working with suppliers and other creditors.
3. Don’t Lie About Debts. When a business starts to have financial troubles, its owner may frantically try to borrow more money. Before doing this, think carefully about whether your business is really likely to do better in the near future or if you’re only likely to compound your debt problems by borrowing more money. If you do decide to apply for a new loan or to consolidate old ones, be forthright in disclosing the financial condition of your business. If you misrepresent your debts to get a loan, the law may regard your new debt as having been obtained by fraud. This would mean you are personally liable for the debts, even if you go through bankruptcy. Where big bucks are involved, the debt could haunt you for many years.
4. Be Careful About Transferring Business Property. Sometimes, out of desperation, a business owner will try to protect personal assets by hiding them. Since creditors are used to ferreting out such hidden assets, by and large these tactics are ineffective and are likely to give rise to civil and even criminal charges of fraud. Specifically, a business owner shouldn’t (1) transfer assets to friends or relatives in an effort to hide them from creditors or from the bankruptcy court, or (2) conceal property or income from a court.
5. Avoid Preferential Payments To Creditors. The Bankruptcy Code frowns on your paying some creditors and not others. This is called "making preferential payments." If you file for bankruptcy, all payments you make during the year before the filing will be scrutinized by creditors to make sure that some creditors weren’t given an unfair advantage by being paid while others received little or nothing. Outside of bankruptcy, if you owe money to creditors who hold collateral, the creditors have special rights in the property that is the security for the debt, but you may legally pay one unsecured creditor ahead of the others.
6. Protect Your Bank Account. If you face serious financial problems and owe money to a bank, it’s often wise to keep most of your checking and other accounts elsewhere. This is because typically your loan agreement gives the bank the right to take your funds without prior notice if the bank thinks you’re in financial trouble. (This is called a "setoff.") It can be a rude surprise to learn that your favorite lender has suddenly drained your checking account.
7. Plan For Ongoing Insurance Coverage. If your business winds up in a Chapter 11 reorganization or you end up in a Chapter 13 reorganization under the Bankruptcy Code, you may have a tough time finding an insurance carrier that’s willing to renew your business coverage or one that’s willing to issue a new policy. So if you’re planning to seek bankruptcy protection, make sure you have insurance in place that extends at least 12 months into the future. You’ll need to make payments on the policy as payments become due, but as long as you pay on time, the insurance can’t be canceled, and you’ll enjoy some peace of mind as you continue in business.
8. Don’t Panic About Utilities Or Your Lease. If you declare bankruptcy, the utility companies can’t use your bankruptcy filing as an excuse for shutting off services, although they can require you to post a reasonable deposit to keep on the lights, phone service and heat. Similarly, as long as you continue to pay your rent, your landlord can’t kick you out. Don’t be spooked by the scary clause commonly placed in commercial leases that says you’re automatically in default if you file for bankruptcy. These clauses are generally not enforceable (but may be enforceable against sub-lessees and assignees).
9. Consider Returning Some Leased Property. If you’re leasing equipment and know you won’t want to retain it after you file for bankruptcy, consider giving it back to the leasing company before you file. If you do so and the equipment is currently worth less than what you owe under the lease, this “deficiency” will get discharged in bankruptcy. On the other hand, if you prefer to keep the leased property, you’ll need to continue making your lease payments on time--when you choose to hang onto leased property, the obligation to make lease payments isn’t discharged by your going through bankruptcy.
10. Don’t Borrow From the Company’s Pension Plan. Many pension plans don’t allow you to borrow (or remove) money from the plan account. If you do, you could be assessed a penalty of up to 115% of the “borrowed” money. Worse, the plan could be "disqualified," meaning that all deductions would be disallowed, all plan assets distributed, and income tax and late payment penalties applied. Other plans may allow you to borrow money for approved purposes, but think twice before you do this: It leaves you with a smaller nest egg, and if you fail to pay back the loan, you could end up paying income taxes on the withdrawal, plus penalties of 10% to 25%.
1. Keep Taxes Current. Rule number one for the owner of any struggling business is to meticulously pay all payroll taxes on time, especially those withheld from employees’ paychecks. Even if you operate your business as a corporation or LLC, the IRS and state tax authorities can hold you personally liable for these taxes plus penalties if they’re not paid. And even if the business goes bankrupt, you are still personally and legally on the hook to pay them.