Report finds that medication errors
WASHINGTON – Medication errors harm 1.5 million people
and kill several thousand each year in the United States, costing the
nation at least $3.5 billion annually, the Institute of Medicine
concluded in a report released on July 20.
According to the report, titled “Preventing Medication Errors“, drug
errors are so widespread that hospital patients should expect to suffer
one every day they remain hospitalized, although error rates vary by
hospital and most do not lead to injury, the report concluded.
The study cited the death of Betsy Lehman, a 39-year-old mother of two
and a health reporter for The Boston Globe, as a classic fatal drug
mix-up. Ms. Lehman died in 1993 after a doctor mistakenly gave her four
times the appropriate dose of a toxic drug to treat her breast cancer.
Recommendations to correct these problems include systemic changes like
electronic prescribing and tips for consumers like advising patients to
carry complete listings of their prescriptions to every doctor’s visit,
the report said.
“The incidence of medication errors was surprising even to us,” said J.
Lyle Bootman, dean of the University of Arizona College of Pharmacy.
“The solutions are complex and far-reaching and will present
The report is the fourth in a series done by the institute, the nation’s
most prestigious medical advisory organization, that has called
attention to the enormous health and financial burdens brought about by
The first report, “To Err Is Human,” was released in 1999 and caused a
sensation when it estimated that medical errors of all sorts led to as
many as 98,000 deaths each year – more than was caused by highway
accidents and breast cancer combined.
After the first report, health officials and hospital groups pledged
reforms, but many of the most important efforts have been slow to take
hold. Drug computer-entry systems, which are supposed to ensure that
hospital patients get the right drugs at the right dose, are used in
just 6 percent of the nation’s hospitals, said Charles B. Inlander,
president of the People’s Medical Society, a consumer advocacy group,
and an author of the Institute of Medicine’s report .
Electronic medical records can help ensure that patients do not receive
toxic drug combinations. The 1999 report urged widespread adoption of
these systems. The July 20, 2006 report called for all prescriptions to
be written electronically by 2010.
Just 3 percent of hospitals have electronic patient records, said Henri
Manasse, chief executive of the American Society of Health-System
Pharmacists. Few doctors prescribe drugs electronically. Even simple
medication safety recommendations – block printing on hand-written
prescription forms – are widely ignored.
Arthur Levin, director of the Center for Medical Consumers and an author
of the 1999 report, said that just about everyone in the health system
was to blame. “This country has not taken seriously the alarms we
sounded in 1999,” Mr. Levin said. “Why?”
Health organizations defended their efforts. Alicia Mitchell, a
spokeswoman for the American Hospital Association, said that since 1999
hospitals had “actively engaged in looking at using information
technology to improve patient safety.”
A recent poll by the association of its members found that 92 percent
intended to adopt electronic patient records, Ms. Mitchell said. But
such systems are complicated and need to be built gradually, she said.