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Institute of Medicine report strives to reduce medication errors

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7561.220-f (Published 27 July 2006) Cite this as: BMJ 2006;333:220

Washington Bob Roehr

Injuries related to drug treatment harm at least 1.5 million Americans each year, resulting in an additional $3.5bn (£1.9bn; €2.8bn) in hospital spending, says a report by the US Institute of Medicine.

The report was commissioned by the Centers for Medicare and Medicaid Services at the direction of Congress and released on 20 July.

It found that drug related errors are the most common medical errors and can occur at every stage from prescription through to monitoring the patient's response. The report estimates that on average at least one drug error per hospital patient occurs each day and says that the rate of error varies widely among facilities. Not all errors, however, lead to injury.

The institute's 1999 report To Err is Human first brought to wide public attention serious problems with quality control in the delivery of health care, said J Lyle Bootman, dean of the College of Pharmacy at the University of Arizona, Tucson, and co-chairman of the committee that wrote the most recent report.

That recognition in 1999 was the beginning of implementation of changes to correct the problems, which this report continues to advance, he said. “There are many avenues for error at the patient level. That is why we specify, right up front, [that] the patient needs to be heavily engaged in this process,” Dr Bootman said. Better communication, including both sides of the patient-provider partnership, was crucial, he added.

“Patient safety in general—and medication safety in particular—is not part of the curriculum at most professional schools,” said a committee member, Albert Wu, a professor of health policy and management at Johns Hopkins University, Baltimore. He called it “a core competency” that doctors should be getting from the very beginning of medical school.

The report recommends that “by 2008 all healthcare providers should have plans in place to write prescriptions electronically.” And it set a date of 2010 by when all healthcare providers should be using electronic prescribing systems and all pharmacies should be able to receive prescriptions electronically, to reduce the scope for error.

The committee lamented the limited amount of data on operational aspects of drug delivery. It called for more funding for research in this area from the few million dollars a year that is currently spent to a minimum annual investment of $100m.

Dr Wu said, “If medication errors were a single disease we would be investing more heavily. Research funding for cancer is in the billions, yet the proportion of people who suffer from medication errors is far greater than those with cancer.”

Preventing Medication Errors can be bought at www.nap.edu/catalog/11623.html.

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