Mistakes with drug dosages prompt need for new system

Lauran Neergaard

WASHINGTON — Medication mistakes injure well over 1.5 million Americans every year, a toll too often unrecognized and unfought, says a sobering call to action.

At least a quarter of the errors are preventable, the Institute of Medicine (IOM) said last Thursday in urging major steps by the government, health providers and patients alike.

Topping the list: All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines.

Perhaps the report’s most stunning finding was that, on average, a hospitalized patient is subject to at least one medication error per day.

A serious drug error can add more than $8,750 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.

“I’m a patient-safety researcher, [yet] I was surprised and shocked at just how common and how serious a problem this is,” said Dr. Albert Wu of Johns Hopkins University, co-author of the report, which was released last Thursday.

Worse, there’s too little incentive for health providers to invest in technology that could prevent some errors today, added Dr. J. Lyle Bootman, the University of Arizona’s pharmacy dean, who co-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.

The new probe couldn’t say how many of the injuries are serious, or how many victims die. A 1999 estimate put deaths, conservatively, at 7,000 a year.

Even the total injury estimate is conservative, Bootman stressed. It includes drug errors in hospitals, nursing homes and among Medicare outpatients, but it doesn’t attempt to count mix-ups in most doctors’ offices or by patients themselves.

There have been efforts to improve patient safety in the six years since the IOM first spotlighted medical mistakes of all kinds, including recent bar-coding of drugs to minimize mix-ups in hospitals and pharmacies.

But clearly more are needed, and the new report highlights how the nation’s fragmented health care system is conducive to drug errors, said Dr. Donald Berwick, a Harvard professor who heads the nonprofit Institute for Healthcare Improvement.

“This isn’t a matter of doctors and nurses trying harder not to harm people,” Berwick cautioned. “Safety isn’t automatic. It has to be designed into the system.”

Medications’ sheer volume and complexity illustrate the difficulty. There are more than 10,000 prescription drugs on the market, and 300,000 over-the-counter products. It’s impossible to memorize their different usage and dosage instructions, which may vary according to the patient’s age, weight and other risk factors, such as bad kidneys.

Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take at least five. The more you use, the greater your risk of bad interactions, especially if multiple doctors prescribe different drugs without knowing what you already take.

Add doctors’ notoriously bad handwriting and sound-alike drug names: Was that order for 10 milligrams or 10 migrams? The hormone Premarin or the antibiotic Primaxin?

Moreover, consumer instructions are 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-age man squirted two puffs into the air and tried to breathe the mist. His original doctor had demonstrated the inhaler without telling him to spray it inside his mouth.

Among the report’s recommendations:

• The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible.

Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. 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 patient’s records show use of another drug that can dangerously interact.

• Patients and their families must be aggressive in questioning doctors, nurses and pharmacists about medications. Get a list of each drug you’re prescribed, why and the dose from each doctor and pharmacy you use, and show it at every doctor visit.

“Take active steps to make sure you know what you’re getting, and is it what you need,” said report co-author Dr. Wilson Pace of the University of Colorado.

• 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 consumer-confusing jargon.

• 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 an independent organization chartered by Congress to advise the government on health matters.

(Associated Press)