Drug errors injure more than 1.5 million

a year

Mistakes are widespread, preventable and costly, report says.

By Thomas H. Maugh II LOS ANGELES TIMES Friday, July 21, 2006

At least 1.5 million Americans are injured or killed every year by medication errors at a direct cost of billions of dollars, according to a report issued Thursday by the Institute of Medicine.

Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she fills a hospital bed, the report states.

The report is a follow-up to a 1999 report from the institute, which is part of the National Academy of Sciences, that outlined all medical errors and claimed that as many as 98,000 people are killed each year as a result of medical errors 7,000 as a result of medication errors.

"We were initially quite surprised by the number of mistakes. But the more we heard, the more convinced we were that these are actually serious underestimates," said panel member Dr. Kevin Johnson of Vanderbilt University.

The study lays out a detailed series of recommendations for new procedures and research to minimize the risk of future medication errors, emphasizing computerization of prescribing and administering drugs.

Betsy Lehman, a health reporter for The Boston Globe, was one patient who died as a result of such errors, according to the report. The 39-year-old wife and mother of two was being treated for breast cancer in an experimental program at the Dana-Farber Cancer Institute in 1994.

A medical fellow wrote a prescription for the cancer drugs citing the total amount she was to receive over four days, the report stated. She died when nurses administered that total each day, overwhelming her system.

The hospital had no system in place to monitor dosages, and her family argued that staff did not pay attention to her complaints about the effects of the overdose, the report stated.

Such mistakes happen all too frequently, according to the report. Each year, an estimated 400,000 preventable drug-related injuries occur in hospitals, costing at least $3.5 billion.

There are also 800,000 medication-related injuries in nursing homes and long-term care facilities, and about 530,000 among Medicare recipients in outpatient clinics. The report provided no estimate on the cost of the errors in those facilities.

"We've made significant improvements since 1999 . . . but we still have a long way to go," said J. Lyle Bootman of the University of Arizona College of Pharmacy, who co-chaired the panel. "The current process by which medications are prescribed, dispensed, administered and monitored is characterized by many serious problems that threaten both the safety and positive outcomes of patients."

With more than 4 billion prescriptions written each year in the United States, even a minute error rate can translate into a large number of problems.

Among the drugs most commonly associated with errors in hospitals are insulin, morphine, potassium chloride and the anti-coagulants heparin and warfarin.

The report cited a 2002 study from the United States Pharmacopeia that found these five drugs accounted for 28 percent of all errors that resulted in extended hospitalizations.

Insulin accounted for a third of that total.

The panel cited a variety of causes for the problems.

One is unexpected drug interactions. With more than 15,000 prescription drugs in use and 300,000 over-the-counter products, "it is virtually impossible for a human to track all the interactions any more," said Dr. Wilson W. Pace of the University of Colorado.

Another is the similarity between drug names, which often results in the wrong drug being given. For example, Fosamax, the osteoporosis drug, could be mistaken for Flomax, given to improve urination in patients with an enlarged prostate.

Other problems include the bad handwriting of physicians, nurses giving patients drugs meant for others, pharmacists dispensing the wrong drugs and patients not understanding how to take the drugs.

The report cites a middle-age man who was not helped by an asthma inhaler. Demonstrating how he used it, he puffed it into the air in front of him and inhaled just as the doctor had done. Because he was illiterate, he could not read the package instructions, which said to puff it directly into his lungs.

"If you are not sure of something, ask," said panelist Albert W. Wu of Johns Hopkins University. "It may be a little bit of an annoyance to providers, but we will get used to it."

Patients also share some of the blame, often withholding information about supplements and herbal medications that they are taking, some of which can have serious interactions with prescription drugs.