Drug mistakes hurt 1.5 million yearly

Hospital patients can expect an error a day
Chicago Tribune
Jul. 22, 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.

For hospitalized patients, the report said that on average one medication error per day is caused by confusion in drug names, wrong doses, failure to deliver drugs and a host of other problems.

The report is a follow-up to a 1999 report from the institute, which is part of the National Academy of Sciences. That report outlined all medical errors and said up to 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 recommendations for new procedures and research to minimize the risk of future medication errors, emphasizing computerization of prescribing and administering drugs and data acquisition.

Betsy Lehman, a health reporter for The Boston Globe, was one patient killed 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 said. She died when nurses administered that total each day, overwhelming her system.

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

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

There are also 800,000 medication-related injuries in nursing homes and other long-term care facilities and about 530,000 among Medicare recipients in outpatient clinics. The report provided no estimate of 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 was co-chairman of 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 U.S., even a very small 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 anticoagulants heparin and warfarin, which have a high risk of patient injury when dispensed incorrectly.

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