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The IOM Medication Error Report

The following are some resources related to the latest IOM Report, including key quotes from IOM and direct links.

Almost everyone in the modern world takes medication at one time or another. According to one estimate, in any given week four out of every five U.S. adults will use prescription medicines, over-the-counter drugs, or dietary supplements of some sort, and nearly one-third of adults will take five or more different medications.

THE UNACCEPTABLE COSTS OF MEDICATION ERRORS
In hospitals, errors are common during every step of the medication process—procuring the drug, prescribing it, dispensing it, administering it, and monitoring its impact—but they occur most frequently during the prescribing and administering stages. When all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day. However, substantial variations in error rates are found across facilities.  An ADE arising from an error is considered preventable. It is difficult to get accurate measurements of how often preventable ADEs occur. One study estimated 380,000 preventable ADEs in hospitals each year, another estimated 450,000, and the committee believes that both are likely to be underestimates. 

The numbers are equally disturbing in other settings. One study calculates, for example, that 800,000 preventable ADEs occur each year in long-term care facilities. Another finds that among outpatient Medicare patients there occur 530,000 preventable ADEs each year. And the evidence suggests that both of these numbers are likely to be underestimates as well. Furthermore, none of these studies includes errors of omission—failures to prescribe medication in cases where it should be. Taking all of these numbers into account, the committee concludes that there are at least 1.5 million preventable ADEs that occur in the United States each year. The true number may be much higher.

Currently, fewer than 20 percent of prescriptions are electronic.  Three percent of hospitals have electronic health records, the New York Times reported.

1. Medication Safety Public Report Release - IOM 7/20/06
2. Report Brief. Preventing Medication Errors - IOM, 7/20/06 [406K, 4 pages]
3. Fact Sheet. What You Can Do to Avoid Medication Errors - IOM, 7/20/2006
4. IOM Full Report - only available for sale as download or print copy, $47.50 and up.
5. Report: Drug errors injure more than 1.5M  AP/Yahoo News  7/20/06
6. Mark McClellan, M.D., PH.D., CMS speaks to IOM Report - CMS release, 7/20/06
7. NPR Discusses IOM Report on Medication Errors, E-prescribing - NPR's "Talk of the Nation/Science Friday" on 7/28/06 discussed a recent Institute of Medicine report finding that all prescriptions should be written electronically by 2010 in an effort to reduce prescription drug errors. Audio.

Related Articles and Reports

Bar Code Technology Could Help Curb Drug Errors at Hospitals Serious injuries reported to FDA because of hospital drug errors have doubled in the last decade. A bar code technology system that verifies the medication and dosage prior to being administered to patients could help curb the increasing number of medication errors, but fewer than 20% of U.S. hospitals have adopted the expensive systems.
>  "Hospital drug errors far from uncommon"  Los Angeles Times, 11/22/07.

Prescription Drug Safety: Emergency Controls, Scams and Long-distance Sales - NCSL report covering anti-terrorism and natural disaster situations from a health and safety perspective.  Updated 11/07.

"Wide Gap Between Vision For E-Prescribing And Reality In Physician Practices;" Physicians Report Major Barriers To Using Advanced E-Prescribing Features; "Physicians’ Experiences Using Commercial E-Prescribing Systems" - full text, PDF.  Health Affairs new 4/3/07.  

Georgetown Suspends E-prescribing Pilot After Security Breach - Georgetown University Hospital in Washington, D.C., last week suspended an electronic prescription pilot program after learning of a data security breach affecting between 5,600 and 23,000 patients.  Wired News 7/26/06.

Expert Sources: Committee on Identifying and Preventing Medication Errors, Institute of Medicine.

Research for Adverse Drug-Events And Reports (RADAR) - "Serious adverse drug reactions (sADRs) account for over 100,000 deaths annually. Investigation into barriers in identification and dissemination of sADR information for drugs is likely to have a direct benefit on patient safety, save lives, and identify areas for future policy changes. These considerations are especially important for cancer drugs, where the emphasis has been on accelerated FDA approval and shorter review times, raising concern that attention to sADRs may not be sufficient."  Study by Charles Bennett, MD, MPH, Northwestern University, 2005.

Legislation excerpted from NCSL State Prescription Drug reports of 2003, 2004, 2005, 2006 and 2007, available online.  Compiled by the NCSL Health Program - Denver.

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This report is posted online at:  www.ncsl.org/programs/health/RxErrors.htm

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