Medical Errors Abound - Many Can Kill You

Medication Errors Harming Millions, Report Says: Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine

I have been talking to my personal physician regarding his practice being too busy to give proper attention to some issues. One of those issues is that his office staff are responsible for writing out scripts and giving them to patients without stringent review. He reviews all the controlled substance prescriptions, but his staff sign his scripts that do not require a "blue script pad." The problem is that medication errors have occurred. In my case, one of my medications was reduced by half and I did not notice until it was filled. Luckily, the medication is not used for life-threatening issues and it only affected my daily life in a minor way. But this study demonstrates that we need more attention paid to not only the training of medical workers, but also on stringent cross-checking of medication prescribing practices.

In surgical operating rooms they have implemented some basic steps that seem redundant, but have effectively reduced some of the more common OR errors, like operating on the wrong side of the body or the wrong patient. We need to implement some of those steps in our medical offices, clinics, ERs and other treatment facilities.

While I am thinking about it, my doctor needs to re-train his office staff on taking a blood pressure.

At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications, the influential Institute of Medicine concluded in a major report released yesterday.

Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she occupies a hospital bed, the report by a panel of experts said.

Following up on its influential 2000 report on medical errors of all kinds, the institute, a branch of the National Academies, undertook the most extensive study ever of medication errors in response to a request made by Congress in 2003 when it passed the Medicare Modernization Act.

The report found errors to be not only harmful and widespread, but very costly as well. The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be $3.5 billion a year.

"Even I was surprised and shocked by how common and serious a problem this is," said panel member Albert Wu, a drug safety specialist at Johns Hopkins University. "Everyone in the health-care system has to wake up and take this more seriously."

Many of these medication errors could be avoided if doctors adopted electronic prescribing, if hospitals had a standardized bar-code system for checking and dispensing drugs, and if patients made more of an effort to know about the risks of the drugs they take, the report said.

The panel members said the problem requires immediate action and that many key players in health care have been slow to take the steps -- and invest the money -- needed to significantly reduce medication errors. At least a quarter of the injuries caused by drug errors are clearly preventable, the report said.

"Everyone in the health-care system knows this is a major problem, but there's been very little action, and it's generally remained on the back burner," panel member Charles B. Inlander said in an interview. "With this report, we hope to give everyone involved good, hard information on how they can prevent medication errors, and then create some pressure to have them implement it."

Common errors include doctors writing prescriptions that could interact dangerously with other drugs a patient is taking, nurses putting the wrong medication -- or the wrong dose -- in an intravenous drip and pharmacists dispensing 100-milligram pills rather than the prescribed 50-milligram dose.

The report spotlighted the case of Betsy Lehman, a 39-year-old health reporter for the Boston Globe who died in 1994 after being given an erroneously high dosage of an experimental chemotherapy agent.

The study, funded by the Centers for Medicare and Medicaid Services, was assembled by 17 experts in related fields who analyzed research in the field, as well as government reports and data. They also held public forums to hear from representatives from the health-care system.