Published January 13, 2015
More than 1.5 million Americans are injured every year by drug errors in hospitals, nursing homes and doctor's offices, a count that doesn't even estimate patients' own medication mix-ups, says a report that calls for major steps to increase patient safety.
Topping that list: All prescriptions should be written electronically by 2010, the Institute of Medicine said. At least a quarter of all medication-related injuries are preventable, the institute concluded in the report it released Thursday.
Perhaps the most stunning finding of the report was that, on average, a hospitalized patient is subject to at least one medication error per day, despite intense efforts to improve hospital care in the six years since the institute began focusing attention on medical mistakes of all kinds.
The new probe couldn't say how many victims of drug errors die. A 1999 estimate put the number of deaths, conservatively, at 7,000 a year. Also unknown is how many of the injuries are serious.
But a preventable drug error can add more than $5,800 to the hospital bill of a single patient. Assuming that hospitals commit 400,000 preventable drug errors each year, that's $3.5 billion — not counting lost productivity and other costs — from hospitals alone, the report concluded.
"The numbers are big. The injuries are big. This is a problem, it's serious and it continues," said report co-author Michael Cohen, president of the Institute for Safe Medication Practices.
Technology alone could prevent some errors today, but there's too little incentive for hospitals and other care providers to invest, added University of Arizona pharmacy dean J. Lyle Bootman, who chaired the IOM probe.
"We're paid whether these errors occur or not," lamented Bootman, who recently experienced the threat firsthand as his son-in-law dodged some drug near-misses while in intensive care in a reputable hospital.
For now, Bootman advises consumers to be aggressive in questioning doctors, nurses and pharmacists about their medications, whether they're watching over a hospitalized loved one or figuring out their own pills at home.
How to battle drug errors is a particularly vexing issue because of the sheer volume and complexity of today's medications. There are more than 10,000 prescription drugs on the market, and 300,000 over-the-counter products. Many come with vastly different usage and dosing instructions depending on the patient's age, weight and other risk factors, like bad kidneys.
Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take a least five. The more you use, the greater your risk of taking two that interact badly, especially if different doctors prescribed different drugs without knowing what you already take.
But that's far from the only cause. Doctors' notoriously bad handwriting too often leaves pharmacists squinting to determine if the order was for 10 milligrams or 10 micrograms. Sound-alike drug names — the hormone Premarin or the antibiotic Primaxin? — can confuse health worker and patient alike.
There also are hospital mix-ups involving where a drug is administered. Consider a rare but horrifying one: Accidentally injecting the cancer drug vincristine into the spinal canal instead of giving it intravenously is almost always fatal, and it's a slow, painful death, said Cohen.
Moreover, the instructions given to consumers on how to take their medicine is woefully inadequate, the report concludes. One study found parents gave their children the wrong dose of over-the-counter fever medicines 47 percent of the time.
Then there was the newly diagnosed asthmatic wondering why his inhaler didn't work. Asked how he used it, the middle-aged man squirted two puffs into the air and tried to breathe the mist. It turns out his original doctor had demonstrated the inhaler without explaining that to work, it had to be sprayed inside the mouth.
Among the report's recommendations:
— The government should take action to speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstore are compatible.
Fewer than about 20 percent of prescriptions currently are electronic, Cohen said. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patients' records show use of another drug that can dangerously interact.
— Health workers must take steps to fully inform patients about medication use, including checking every drug they use before prescribing a new one.
— The nation should invest about $100 million annually on research into drug errors and how to prevent them. Among the most-needed studies is the impact of free drug samples, which often lack proper labeling on medication safety.
— The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs, but often have incomplete information or are written in jargon the average consumer can't understand.
— The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems.
The Institute of Medicine is a branch of the National Academy of Sciences, an independent organization chartered by Congress to advise the government on scientific matters.