]Report Finds Drug Errors Hurt 1.5 Million

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Ilena Rose <ilena.rose@...> wrote: Date: Thu, 20 Jul 2006 12:53:05 -0600From: "Ilena Rose" <ilena.rose@...>Subject: Report Finds Drug Errors Hurt 1.5 Million Jul 20, 12:05 PM EDT Report Finds Drug Errors Hurt 1.5 Million By LAURAN NEERGAARD AP Medical Writer WASHINGTON (AP) -- More than 1.5 million Americans are injured everyyear 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 electronicallyby 2010, the Institute of Medicine said. At least a quarter of allmedication-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 perday, despite intense efforts to improve hospital care in the six years since the institute began focusing attention on medical mistakes ofall kinds. The new probe couldn't say how many victims of drug errors die. A 1999estimate 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 hospitalbill of a single patient. Assuming that hospitals commit 400,000preventable drug errors each year, that's $3.5 billion - not counting lost productivity and other costs - from hospitals alone, the reportconcluded. "The numbers are big. The injuries are big. This is a problem, it'sserious and it continues," said report co-author Cohen,president of the Institute for Safe Medication Practices. Technology alone could prevent some errors today, but there's toolittle 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, whorecently experienced the threat firsthand as his son-in-law dodgedsome drug near-misses while in intensive care in a reputable hospital. For now, Bootman advises consumers to be aggressive in questioningdoctors, nurses and pharmacists about their medications, whetherthey'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 ofthe sheer volume and complexity of today's medications. There are

morethan 10,000 prescription drugs on the market, and 300,000 over-the-counter products. Many come with vastly different usage anddosing instructions depending on the patient's age, weight and otherrisk factors, like bad kidneys. Plus, four of every five U.S. adults take at least one medication ordietary supplement every day; almost a third take a least five. Themore you use, the greater your risk of taking two that interact badly, especially if different doctors prescribed different drugs withoutknowing what you already take. But that's far from the only cause. Doctors' notoriously badhandwriting too often leaves pharmacists squinting to determine if theorder was for 10 milligrams or 10 micrograms. Sound-alike drug names - the hormone Premarin or the antibiotic

Primaxin? - can confuse healthworker and patient alike. There also are hospital mix-ups involving where a drug isadministered. Consider a rare but horrifying one: Accidentallyinjecting 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 theirmedicine is woefully inadequate, the report concludes. One study foundparents 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 inhalerdidn't work. Asked how he used it, the middle-aged

man squirted twopuffs into the air and tried to breathe the mist. It turns out his original doctor had demonstrated the inhaler without explaining thatto 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 myriadcomputer 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. Thecomputer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patients'

records show use ofanother drug that can dangerously interact. -Health workers must take steps to fully inform patients aboutmedication use, including checking every drug they use beforeprescribing a new one. -The nation should invest about $100 million annually on research intodrug errors and how to prevent them. Among the most-needed studies isthe impact of free drug samples, which often lack proper labeling on medication safety. -The Food and Drug Administration should improve the quality of druginformation leaflets that accompany prescription drugs, but often haveincomplete information or are written in jargon the average consumer can't understand. -The government should establish national telephone hotlines to helppatients unable to understand printed drug information because ofilliteracy, language barriers or other problems. The Institute of Medicine is a branch of the National Academy ofSciences, an independent organization chartered by Congress to advisethe government on scientific matters. ---~~~~~~~~~~~~~~~~~~~~~~~~~ www.BreastImplantAwareness.org/