Drug errors costing billions

Extent of mistakes surprises experts

1.5 million hurt


Medication errors injure more than 1.5 million Americans every year at a cost surpassing $3.5 billion, according to a report issued yesterday by the National Academies' Institute of Medicine.

"Every component of the medication process has errors," said Dr. Wilson D. Pace, a professor of family medicine at the University of Colorado and an author of the report.

Estimating that the average hospital patient is subject to one medication error per day, the report pointed to widespread communication problems among medical personnel, drug companies and patients. Among them:

Patients sometimes receive the wrong drugs when doctors' indecipherable handwriting befuddles pharmacists - or when drugs with similar packages confuse nurses.

Without accurate information from patients and drug manufacturers, doctors can prescribe medicines that interact badly with other drugs a patient is taking.

At home, patients take drugs improperly because they did not ask doctors or pharmacists for a clarification. And drug instruction pamphlets are difficult for many patients to understand.

"It is quite sobering," said J. Lyle Bootman, dean of the College of Pharmacy at the University of Arizona and co-chairman of the committee that conducted the study. "We need to bring a lot of this to the surface."

Jennifer Daniels, 32, of Owings Mills experienced this firsthand last July when she was scheduled for gall bladder surgery at Carroll Hospital Center.

Her doctors prescribed intravenous antibiotics as a preoperative precaution, but her nurse picked up an IV bag of insulin by accident. "Before they realized what they were doing, they gave me the whole bag of insulin," Daniels said. "I'm not even a diabetic."

Her blood sugar plummeted and she passed out, but doctors were able to revive her by boosting her blood sugar with glucose. She spent the next two days in the critical care unit before her surgery could proceed.

"It was the first time I'd ever been in the hospital for any kind of surgery," said Daniels, who filed suit against the hospital but settled the case out of court. "It surprised me it was so easy for that to happen."

Nationwide, the extent of medical errors surprised the new report's authors, too. "We all need to wake up and take this more seriously," said Dr. Abert Wu, a professor at the Johns Hopkins Bloomberg School of Public health and co-author of the study. "I am a patient-safety researcher, and I was surprised by all of this."

Yesterday's study was the latest in a series of Institute of Medicine research projects designed to assess and prevent medical errors in the American health care system.

IOM's first report, in 1999, created a public uproar with its estimate that as many as 98,000 people a year die as a result of medical errors. It attributed 7,000 of those deaths to medication errors, and yesterday's report concluded that the problem is still widespread.

The authors suggested ways to correct medication problems, including better drug packaging, with clearer instructions, and a switch to electronic prescription systems by 2010. They also advised patients to be more aggressive in dealing with their doctors and pharmacists.

"The single most important piece of advice I give my patients is to become a more active member of your health care team," said Wu. "Ask questions if you don't understand something. Keep a list of your medications. Get things in writing."

"It may be a prescription for being annoying," he said. "But many of the problems are due to insufficient communication between patient and doctor."

Although much remains to be done, local safety officials say the situation has improved here.

After a 2003 incident in which a 2 1/2 -year-old Hopkins cancer patient died from an overdose of potassium in an intravenous bag delivered to her home, the hospital and its Home Care Group revamped their systems for prescribing and delivering medications.

Meanwhile, in the wake of the IOM's initial report, Maryland legislators asked regulators to create the Maryland Patient Safety Center, which opened in 2004. It tracks incidents involving medication errors and provides safety training for health care workers and patients.

"The reports have not fallen on deaf ears," said Steve Cohen, who heads prevention efforts for MedStar Health, a nonprofit that manages seven hospitals in the Baltimore-Washington region, including Franklin Square and Good Samaritan hospitals.

Cohen said MedStar has implemented a variety of measures, including Web-based systems for hospital workers to report mistakes and near-misses from anywhere in the hospital.

"In the old days, people would fill out incident reports, and it might have taken quite a long time before anybody could do anything to correct it," he said. "Now, we have much stronger processes in place to report errors."

One of the biggest hurdles, he said, has been shifting the blame away from health care workers and identifying flaws in the system that lead to mistakes.

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