The IOM report, Preventing Medication Errors, recommends a series of remedial actions, including getting patients to be more involved in their own health care and conducting more research on the problem. Having all prescriptions filled electronically by the year 2010 is one of several specific recommendations.
"Electronic prescribing is safer," said J. Lyle Bootman, co-chair of the committee that wrote the report and dean of the College of Pharmacy at the University of Arizona in Tucson.
This is not the first time the Institute of Medicine has broached this topic. In 1999, the organization published a landmark report called To Err Is Human: Building a Safer Health System, which identified a range of patient safety problems and called for improvements.
That report found that at least 7,000 Americans die every year as the result of medication error. Although there have been some improvements, much still needs to be done, the
new report said.
"The report that we are releasing today makes clear that, with regard to medication errors, we still have a long way to go," said Bootman. "The system is characterized by many serious problems that threaten the safety and positive outcomes we hope to achieve when we serve patients."
Medication errors occur at virtually every stage of care, including in administration and at the patient's own hand. Existing studies suggest that 400,000 preventable drug-related injuries occur each year in hospitals, another 800,000 in long-term care settings, and about 530,000 among Medicare recipients in outpatient clinics.
One study found that medication-related injuries among Medicare recipients in outpatient clinics alone resulted in about $887 million in extra medical costs in 2000.
The report suggests that patients could do much to protect themselves.
"We tell the public to take an active role in their own health care, and ask about the risks and benefits of each medication," said Dr. Wilson Pace, another member of the report committee and a professor of family medicine at the University of Colorado, in Aurora. The report provides a list of questions to ask health-care providers.
And health-care providers and organizations need to inform patients about medication errors, even if the error doesn't result in harm.
The report also recommended that the U.S. Food and Drug Administration work with other groups to standardize medication leaflets, making sure they are user-friendly in the process.
"The Food and Drug Administration believes the Institute of Medicine report provides a much needed perspective on the frequency, severity and preventable nature of medication errors," the FDA said in a prepared statement released Thursday. "We find that many of the recommendations outlined in the report are supported by efforts already under way at FDA in the areas of medication error prevention, patient education and label comprehension."
The report also suggested that the National Library of Medicine should be in charge of online health resources for consumers, and should create one centralized Web site for information about drugs.
"There are upwards of 15,000 medications available today," Pace said. "It's impossible to track with your memory. We're advocating decision-support systems."
The report also called for improvements in drug labeling and packaging, and in naming drugs.
Many of the recommendations are in line with processes already required by the Joint Commission on Accreditation of Healthcare Organizations. For instance, there's medication reconciliation, which requires three steps whenever a patient goes through a transition, such as moving from intensive care to a regular nursing unit. "The first is getting a medication list of what the patient was taking before the transition," Griffin explained. "Second is using that list as a reference while new orders are being written, and third is doublechecking and making sure any changes have documentation."
"It's more complex than it would appear on the surface," she added. "There's no one place that a patient's medication lives. Whenever there's a transition, we have to start over."
The IOM recommendations would carry costs, the report authors conceded.
"Of course, there will be costs," Bootman said. "But there are serious costs associated with the occurrence and incidence of medication errors."
"This issue is quite sobering to all of us, and it's one we need to bring to the surface," Bootman continued. "The good news is that many of these injuries are preventable. Some, we can implement tomorrow morning, and we will begin to see success. Others will take more investment."
More information
Visit the Institute of Medicine for more on the report. |
