Medication errors are among the most common medical mistakes, impacting at
least 1.5 million people every year, according to the Institute of Medicine
The extra medical costs of treating drug-related injuries occurring in
hospitals alone conservatively amount to $3.5 billion a year, and this
estimate does not take into account lost wages and productivity or additional
health care costs, the IOM states in a new report, "Preventing
The report is the fourth IOM paper in its "Quality Chasm
Series," begun in 1996. Previous reports include "To Err Is
Human" (2000), "Crossing the Quality Chasm" (2001), and"
Patient Safety" (2004).
The new report offers specific recommendations for physicians, health
systems and hospitals, and patients in four broad categories: improving the
patient-provider partnership; improving drug-information resources; electronic
prescribing and other IT solutions; and drug naming, labeling, and
"The frequency of medication errors and preventable adverse drug
events is cause for serious concern," said committee co-chair Linda
Cronenwett, Ph.D., dean and professor at the University of North Carolina
School of Nursing, in a statement released with the report. "We need a
comprehensive approach to reducing these errors that involves not just health
care organizations and federal agencies, but the industry and consumers as
Some of the important recommendations under each of the four broad
categories are as follows:
The report provides consumers with a list of questions to ask health care
providers, such as how to take their medications properly and what to do if
side effects occur. Also included are actions consumers should take, such as
requesting that their clinicians give them a printed record of the drugs they
have been prescribed. Patients should maintain an up-to-date list of all
medications they use—including over-the-counter products and dietary
supplements—and share it with all their health care providers. This list
should also note the reasons they are taking each product and include drug and
The IOM called on the National Library of Medicine (NLM) to be the chief
agency responsible for online health resources for consumers; it should create
a Web site to serve as a centralized source of comprehensive, objective, and
easy-to-understand information about drugs for consumers.
The report also recommended that NLM, FDA, and the Centers for Medicare and
Medicaid Services evaluate ways to build and fund a national network of
telephone helplines to assist people who may not be able to access or
understand printed medication information because of illiteracy, language
barriers, or other obstacles.
All health care provider groups should be actively monitoring their
progress in improving medication safety, the committee recommended. Monitoring
efforts might include computer systems that detect medication-related problems
and periodic audits of prescriptions filled in community pharmacies.
The FDA, AHRQ, and the pharmaceutical industry should collaborate with
United States Pharmacopeia, Institute for Safe Medication Practices, and other
appropriate organizations to develop a plan to address the problems associated
with drug naming, labeling, and packaging by the end of 2007.
The report also recommends studies to evaluate the impact of free drug
samples on overall medication safety.
Responding to the report, APA immediate past President Steven Sharfstein,
M.D., emphasized the importance of the physician's relationship with patients
in the reduction of medication errors.
"I do believe that health care organizations, including hospitals,
should inform patients of all errors, including medication errors, even if
there is no harm," he said. "It is important that patients and
families are part of a safety-first culture, and patient-family education is
very high on the priority list these days. Including patients and families in
the formation of a treatment plan is increasingly seen as critical to its
Al Herzog, M.D., chair of APA's Patient Safety Committee, told
Psychiatric News that studies of errors across medical specialties
suggest psychiatry is not different from other areas of medicine.
"Serious errors that cause true patient harm happen when treating
patients with multiple diagnoses and involve matters such as wrong dose and
wrong medicine with medications whose names look and sound alike," he
said. "Insulin and coumadin orders on inpatient units present special
challenges because of the close relationship between dose and effect.
Arrhythmias with some of the antipsychotics and older antidepressants also
need to be watched."
Herzog emphasized especially that a "systems analysis"
perspective on errors—which regards medication and other medical errors
as occurring in the context of a system of care—should replace the
current adversarial approach to blaming individual physicians.
"I can't overestimate the importance of looking at this as a system
issue rather than `you are a bad doctor/nurse' issue," he said."
Hopefully, all of us are taking a time-out when a mistake is made to
learn from our root-cause analyses. The IOM report makes that point over and
The IOM study was sponsored by the U.S. Department of Health and Human
Services and Centers for Medicare and Medicaid Services. Established in 1970
under the charter of the National Academy of Sciences, the Institute of
Medicine provides independent, objective, evidence-based advice to
policymakers, health professionals, the private sector, and the public.
A prepublication copy of "Preventing Medication Errors"
is available from the National Academies Press by phone at (202) 334-3313 or
(800) 624-6242 or online at<www.nap.edu>.▪