IOM Report: Medication Errors

New IOM Report highlights the increasing incidence of medication errors.Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a new report see http://www.iom.edu/CMS/3809/22526/35939.aspx Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said. As physicians we should proactively undertake every reasonable effort to reduce the incidence of medication errors. I use electronic prescribing for several years and have caught multiple errors related to drug-interactions, wrong dosage and limited legibility issues.

Institute Cites Medication Errors,
Suggests Changes to Cut Injuries
By SHIRLEY S. WANG
WSJ July 21, 2006; Page A11
Medication errors serious enough to cause injury occur 1.5 million times a year in the U.S., according to a report released by the Institute of Medicine of the National Academies.
The report makes ambitious recommendations for reducing the rate of errors, with U.S. agencies taking the lead, and recommends deadlines. It calls for $100 million in research to determine the best and most cost-effective measures.
A previous report from the IOM, which in 1999 estimated that medical errors of all types were responsible for as many as 98,000 deaths a year, spurred the government to pour $50 million into patient-safety initiatives and invigorated efforts among health-care providers and insurers to reduce errors. Hospitals are working on a number of initiatives, including the use of electronic order-entry systems.
The report recommends that all health-care providers use an electronic system to prescribe drugs by 2010. "Large hospitals are pretty much invested in moving in that direction," J. Lyle Bootman, dean at the University of Arizona College of Pharmacy said, though other medical settings, such as long-term-care facilities, may need more help with implementation. Dr. Bootman was co-chairman of the Committee on Identifying and Preventing Medication Errors, which drafted the IOM report.
The report also found that confusing drug labels and packaging are responsible for one-quarter to one-third of medication errors, including 30% of all medication-error deaths. The report urged the Food and Drug Administration and the federal Agency for Healthcare Research and Quality to work with industry to address problems by the end of 2007 and possibly standardize drug names and labels.
The report recommended that the National Library of Medicine create a centralized online database on drugs to help consumers. The NLM should also spearhead an initiative with the FDA and Centers for Medicare and Medicaid Services to consider a nationwide telephone hot line for people who can't read printed materials.
July 21, 2006

Report Finds a Heavy Toll From Medication Errors
By GARDINER HARRIS
WASHINGTON, NYT July 20 — Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a report released on Thursday.
Drug errors are so widespread that hospital patients should expect to suffer one every day they remain hospitalized, although error rates vary by hospital and most do not lead to injury, the report concluded.
The report, “Preventing Medication Errors,” cited the death of Betsy Lehman, a 39-year-old mother of two and a health reporter for The Boston Globe, as a classic fatal drug mix-up. Ms. Lehman died in 1993 after a doctor mistakenly gave her four times the appropriate dose of a toxic drug to treat her breast cancer.
Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said.
“The incidence of medication errors was surprising even to us,” said J. Lyle Bootman, dean of the University of Arizona College of Pharmacy. “The solutions are complex and far-reaching and will present challenges.”
The report is the fourth in a series done by the institute, the nation’s most prestigious medical advisory organization, that has called attention to the enormous health and financial burdens brought about by medical errors.
The first report, “To Err Is Human,” was released in 1999 and caused a sensation when it estimated that medical errors of all sorts led to as many as 98,000 deaths each year — more than was caused by highway accidents and breast cancer combined.
After the first report, health officials and hospital groups pledged reforms, but many of the most important efforts have been slow to take hold.
Drug computer-entry systems, which are supposed to ensure that hospital patients get the right drugs at the right dose, are used in just 6 percent of the nation’s hospitals, said Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, and an author of the report released Thursday.
Electronic medical records can help ensure that patients do not receive toxic drug combinations. The 1999 report urged widespread adoption of these systems. Thursday’s report called for all prescriptions to be written electronically by 2010.
Just 3 percent of hospitals have electronic patient records, said Henri Manasse, chief executive of the American Society of Health-System Pharmacists. Few doctors prescribe drugs electronically.
Even simple medication safety recommendations — block printing on hand-written prescription forms — are widely ignored.
Arthur Levin, director of the Center for Medical Consumers and an author of the 1999 report, said that just about everyone in the health system was to blame. “This country has not taken seriously the alarms we sounded in 1999,” Mr. Levin said. “Why?”
Health organizations defended their efforts.
Alicia Mitchell, a spokeswoman for the American Hospital Association, said that since 1999 hospitals had “actively engaged in looking at using information technology to improve patient safety.”
A recent poll by the association of its members found that 92 percent intended to adopt electronic patient records, Ms. Mitchell said. But such systems are complicated and need to be built gradually, she said.
Thursday’s report urged the Food and Drug Administration to improve and standardize the drug information leaflets given consumers. It noted that confusing information on drug labels was an important cause of medication errors.
On Tuesday, the drug agency finished a years-long process by issuing voluntary guidelines to reform consumer drug information leaflets, said Dr. Scott Gottlieb, the agency’s deputy commissioner. Many of these leaflets are not regulated by the F.D.A.
And on June 30, the agency completed a lengthy effort to clarify and standardize information on drug labels. The new labels could prevent nearly 300,000 medication errors each year and will make electronic prescribing efforts far easier to carry out, Dr. Gottlieb said.
Thursday’s report said that the common practice whereby drug companies provided free drug samples to doctors should be discouraged because such samples were poorly controlled. It urged drug makers to package more pills in individual packages. And it criticized drug makers as failing to disclose the results of all clinical trials involving their drugs.
Alan Goldhammer, a spokesman for the Pharmaceutical Research and Manufacturers of America, a drug industry trade group, said he differed with some of the report’s conclusions but concurred with the broad goals of increasing the use of information technology to reduce medication errors.
“Everybody is working on that right now,” he said.
Thursday’s report said that in any given week, four out of five adults in the United States took at least one medication. A third take at least five different medications. As the use of medications has soared, so, too have medication errors, Dr. Manasse said.
Effective strategies to prevent such errors have, however, been known for years, Mr. Inlander said.
“This is not rocket science,” Mr. Inlander said. “It’s simple. The key is having the will to make these changes in an organized and uniform way. And it’s not that expensive.”