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Medication Errors Cause Patient Harm

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Yesterday the Institute of Medicine issued a press-release concerning its report on medication errors. According to the Institute of Medicine,

Medication errors are among the most common medical errors, harming at least 1.5 million people every year, says a new report from the Institute of Medicine of the National Academies. 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 report says.

The committee that wrote the report recommended a series of actions for patients, health care organizations, government agencies, and pharmaceutical companies. The recommendations include steps to increase communication and improve interactions between health care professionals and patients, as well as steps patients should take to protect themselves. The report also recommends the creation of new, consumer-friendly information resources through which patients can obtain objective, easy-to-understand drug information. In addition, it calls for all prescriptions to be written electronically by 2010 and suggests ways to improve the naming, labeling, and packaging of drugs to reduce confusion and prevent errors.

Our firm has represented patients who have suffered harm as a result of medication errors so these figures do not surprise me. When prescription volumes increase and insurance reimbursement rates decline, pharmacies looking to reduce costs, rely more and more on cost-cutting techniques. Minimum wage pharmacy technicians now do more and more medication-dispensing work. In the past, specially trained pharmacists performed most prescription dispensing and patient counselling work. As technicians do more and more prescription-filling work, we logically see increases in medication error rates.

Our firm has represented several patitents who have suffered harm as a result of medication errors. One example comes to mind which highlghts these problems. We represented a patient who received a prescription for an allergy medication Zyrtec. Instead, for the next eighteen months, the patient received the anti-psychotic medication Zyprexa. The pharmacy missed several crucial opportunities to prevent this medication error. A trained pharmacist should have counselled the patient correctly on this prescription. Had proper counselling occurred, this error could have been prevented before the patient walked out of the pharmacy. Too often, we see similar medication errors occur in retail pharmacy and hospital settings. Even patients who try to play an active role in their healthcare can still become victims of poor safety procedures inside hospitals and pharmacies.

The Institute of Medicine recommended a series of low-cost changes in the way pharmacies, hospitals, doctors and patients interact. For example, before filling a prescription, pharmacies and hospitals now have to routinely decipher doctors’ hand-written prescriptions. Lets face it, doctors’ handwriting generally could use improvement and can be a great source of confusion and error. Available electronic prescription technology makes the hand-written prescription obsolete. Technology eliminates the need to decipher doctors hand-writing; so rather than requiring pharmacy and hospital employees to become experts in handwriting analysis, using available electronic prescription technology, the Institute of Medicine suggests that prescription error rates will drop,

Even more promising is the use of electronic prescriptions, or e-prescriptions. By writing prescriptions electronically, doctors and other providers can avoid many of the mistakes that accompany handwritten prescriptions, as the software ensures that all the necessary information is filled out–and legible. Furthermore, by tying e-prescriptions in with the patient’s medical history, it is possible to check automatically for such things as drug allergies, drug-drug interactions, and overly high doses. In addition, once an e-prescription is in the system, it will follow the patient from the hospital to the doctor’s office or from the nursing home to the pharmacy, avoiding many of the “hand-off errors” common today. In light of all this, the committee recommends that by 2010 all prescribers and pharmacies be using e-prescriptions.

Moreover, re-arranging the storage of medications on a retail pharmacy shelf based upon volume of use rather than based upon alphabetical listings can minimize the risk of a prescription misfill due to similarly sounding name. The Institute of Medicine suggests further:

Another way to reduce medication errors is to ensure that drug information is communicated clearly and effectively to providers and patients. Some errors occur simply because two different drugs have names that look or sound very similar. With this in mind, the committee recommends that the drug industry and the appropriate federal agencies work together to improve drug nomenclature, including not just drug names but also abbreviations and acronyms. At the same time, the information sheets that accompany drugs should be redesigned, taking into account research that identifies the best methods for communicating information about medications.

Everybody agrees that such high medication error rates are simply unacceptable. These recommended solutions do not cost a great deal and rely upon a systems approach to patient safety. Hopefully by highlighting the problem, the Institute of Medicine can use its leadership to implement these recommended low-cost solutions and rather than seeing 1.5 million medication errors each year, we can see vast improvements in the quality of medication administration.