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Check That Pill: Medication Errors Common, IoM Study Finds

By Mary Agnes Carey, CQ HealthBeat Associate Editor

JULY 20, 2006 -- Medication errors are harming at least 1.5 million people a year, according to an Institute of Medicine (IoM) report released Thursday.

Treating medication errors in hospitals alone costs an estimated $3.5 billion yearly and another $887 million for Medicare beneficiaries. Neither figure, however, accounts for lost earnings or compensation for pain and suffering, according to the report prepared by the IoM, a division of the National Academies.

Studies indicate that 400,000 preventable drug-related injuries occur each year in hospitals, with patients subjected on average to one medication error each day. Another 800,000 medication errors occur in long-term care settings, and roughly 530,000 occur just among Medicare beneficiaries in outpatient clinics, according to the IoM committee, which also noted that the figures are likely underestimates.

The report, mandated by the 2003 Medicare drug law (PL 108-173), lists a series of recommendations for health care providers, patients, federal agencies, and drug manufacturers to help reduce medication errors. Key steps include all prescriptions to be written electronically by 2010 and changes to be made to the labeling, naming, and packaging of drugs to prevent errors.

"Our recommendations boil down to ensuring that consumers are fully informed about how to take medications safely and achieve the desired results and that health care providers have the tools and data necessary to prescribe, dispense, and administer drugs as safely as possible and to monitor for problems," said committee Co-Chair J. Lyle Bootman, dean and professor, College of Pharmacy, University of Arizona, Tucson. "The ultimate goal is to achieve the best care and outcomes for patients each time they take a medication."

One of the best ways to reduce medication errors, researchers found, is to have patients and health care providers operate more as partners, with a particular emphasis on patients playing a greater role in their health care.

"Doctors, nurses, pharmacists, and other providers must communicate more with patients at every step of the way and make that communication a two-way street," a summary of the report states. Patients should know which medications they are taking and be told about the risks, including what to do if they experience a side effect.

The IoM committee recommends that the Food and Drug Administration, the National Library of Medicine, and other government agencies work together to standardize and improve medication information leaflets provided by pharmacies, make more and better drug information available over the Internet, and develop a 24-hour national telephone helpline that offers consumers easy access to drug information.

Senate Finance Committee Chairman Charles E. Grassley, R-Iowa, said the IoM's finding that many medication errors are due to confusion about a drug's name, label, and packaging should spur the FDA to take action.

"Drug names look and sound alike, labels are cluttered, and warnings are given inadequate prominence," Grassley said in a news release.

FDA officials said Thursday that the agency has taken several steps over the last year to address many of the recommendations in the IoM report.

For example, FDA said in a statement, the agency in January called for a major revision to the format of prescription drug information, to give health care providers clearer prescribing information. The agency also said it will continue to evaluate its process for evaluating drug approvals if a drug's name, label or labeling will cause confusion and possibly medication errors. "We plan to issue guidance for industry on drug naming, labeling and packaging as recommended in this report," FDA said.

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