IOM: Medication Errors Affect 1.5M U.S. Residents
At least 1.5 million U.S. residents are harmed or killed each year because of medication errors, leading to at least $3.5 billion annually in extra health care expenses at hospitals to treat the error-related injuries, according to a report released on Thursday by the Institute of Medicine, the Washington Post reports. The report -- requested by Congress in the 2003 Medicare law and funded by CMS -- was compiled by a 17-member expert panel and is considered "the most extensive study ever of medication errors," the Post reports.
For the report, the panel analyzed previous studies along with government reports and data. The panel also conducted public forums to hear comments from health care industry representatives (Kaufman, Washington Post, 7/21). The report finds:
- On average, a patient hospitalized in the U.S. will experience at least one medication error per day (Neergaard, AP/San Francisco Chronicle, 7/21);
- Each year, medication errors cause at least 400,000 preventable injuries and deaths in hospitals, more than 800,000 in nursing homes and long-term care facilities, and more than 530,000 among Medicare beneficiaries treated in outpatient settings (Maugh, Los Angeles Times, 7/21);
- Confusing drug labels and packaging cause one-quarter to one-third of all medication errors and contribute to 30% of all medication-error deaths (Wang, Wall Street Journal, 7/21);
- More than half of patients do not take medications exactly as prescribed (Weise, USA Today, 7/21);
- Hospitals and long-term care facilities typically do not report medication errors to patients or their family members unless the errors result in injury or death; and
- At least one-quarter of injuries caused by medication errors are clearly preventable.
The report, the fourth in a series by IOM to examine medical errors, is a follow-up to a 1999 report that found as many as 98,000 deaths occur annually because of medical errors (Harris, New York Times, 7/21). The 1999 report found that 7,000 medical error deaths are the result of a medication mistake (Los Angeles Times, 7/21).
The report calls on U.S. government agencies to take the lead in implementing steps to reduce medication errors and recommends deadlines for completing such steps. The report recommends the government spend $100 million annually to research the most useful and cost-effective ways to reduce medication errors (Wall Street Journal, 7/21).
Panel Co-Chair J. Lyle Bootman, dean of the University of Arizona College of Pharmacy, said the research should focus on reducing errors in settings where medications are heavily used, including pediatric, psychiatric and long-term care facilities (Washington Post, 7/21). In addition, the report recommends that:
- FDA and the Agency for Healthcare Research and Quality work with the pharmaceutical industry to address problems with drug labels and packaging by the end of 2007 and possibly implement standardized drug names and labels (Wall Street Journal, 7/21);
- All health care providers by 2008 develop plans to transition to electronic prescribing systems (Washington Post, 7/21);
- All health care providers by 2010 begin using electronic prescribing systems (USA Today, 7/21);
- The National Library of Medicine create a central online database for consumers to find information on medications and work with FDA and CMS to consider creation of a nationwide telephone hotline for patients who cannot read printed information (Wall Street Journal, 7/21);
- All health care providers report medication errors to patients and family members, regardless of whether harm occurred (Washington Post, 7/21);
- Pharmaceutical companies disclose all clinical trial results and limit the practice of providing physicians with free samples of medications because the samples are poorly regulated (New York Times, 7/21);
- Pharmaceutical companies package pills in blister packs in order to simplify identification and make it easier for consumers to remember if they took a dose (Washington Post, 7/21);
- Patients maintain a list of all prescription and nonprescription treatments they take and review the document with their health care provider to ensure there are no potential drug interactions; and
- Patients read, understand and abide by medication instructions (USA Today, 7/21).
- CBS' "Evening News": The segment includes comments from Wilson Pace, an IOM panel member and professor at the University of Colorado, and Robert Fakelmann, director of medication safety and clinical services at Hackensack University Medical Center (Kaledin, "Evening News," CBS, 7/20) The complete segment is available online in RealPlayer.
- NBC's "Nightly News": The segment includes comments from Bootman; Bill Churchill, director of pharmacy services at Brigham and Women's Hospital; and Wu (Costello, "Nightly News," NBC, 7/20). The complete segment is available online on MSNBC Video.
- NPR's "All Things Considered": The segment includes comments from Michael Cohen, a co-author of the report and president of the Institute for Safe Medication Practices; Jim Conway, a co-author of the report and former executive at Dana Farber Cancer Institute; Sylvia Bartel, chief pharmacist at Dana Farber; and Inlander (Knox, "All Things Considered," NPR, 7/20). The complete segment is available online in RealPlayer.