From Poor Penmanship to Bad Communication: Many Opportunities for Medication Mishaps

July 20, 2006— -- A doctor's poor penmanship may soon be a thing of the past. Today in a report on medication errors, the prestigious Institute of Medicine called on physicians to electronically prescribe drugs by the year 2010.

While illegible prescriptions are one contributing factor to the 1.5 million people harmed each year by medication errors, they are not the only culprit.

The report identified patients, pharmacists, drug manufacturers, hospitals, nursing homes and doctors as contributors to the costly problem. The extra medical expense because of errors that occur in hospitals alone add up to at least $3.5 billion a year, the report said.

With approximately four out of five adults in the United States taking at least one medication a week, there is a lot of room for medication mishaps.

Some of the most common problems are dosage, allergy and drug interaction errors. While some mistakes result in injury and death, most do not.

Dr. Neil Brooks, a family doctor in Vernon, Conn., recalled a patient who was accidentally given a sleeping pill instead of the laxative he had prescribed. The mistake occurred because the drug names doxidan and doriden were similar, he said. The patient continued to be constipated but was happy to get a restful night's sleep, he added.

However, it's important to stop all medication errors, even those that do not cause injury or death, because "they can all become serious," said Charles Inlander, one of the authors of the report, and president of the People's Medical Society, a consumer health advocacy group.

To this end, the report recommends that patients be informed and suggests it is a patient's right to know of all medication errors regardless of harm to patients.

"These are errors that can be fixed," said Inlander. There should be "zero tolerance" for medication mishaps, he added.

Everyone from doctors and patients to pharmacists and drug companies are part of the solutions the report recommends.

Keeping an updated medication list, double-checking the name of the drug dispensed at the pharmacy and asking more questions of doctors and pharmacists are just three of the many things patients can do to minimize their risk of a medication error.

Better Communication Between Pharmacists and Doctors

The report also encourages pharmacists and doctors to provide patients with more verbal and written information about their medications.

The information from the pharmacist and doctor should be the same to avoid confusing the patient, Inlander said. Currently patients sometimes receive conflicting information from the different sources.

Authors recommend that the drug information be obtained from a common Web site developed and maintained by the National Library of Medicine. Patients, family members and health care providers could go to the Web site, a "centralized source of comprehensive, objective, easy to understand information," wrote the report authors. It would provide side effects, drug interactions, dosages as well as other information.

Pharmacists could help reduce medication mishaps by improving labels on pill bottles, according to the report. Labels that are larger or color-coded and pill bottles of different shapes may help minimize errors for people who have trouble reading the labels.

The report recommended that drug manufacturers put a bar code on every pill so that when given in a hospital the pills could be matched against the patient's wristband, also with a barcode. Another area for improvement is in the naming of drugs, as similar names can also result in confusion. The companies are also encouraged to improve the packaging of medications.

"If they just used that bubble packaging, I think people could get it right," said Laura Watkins of Needham, Mass., who takes eight different pills a day. The packaging, known as pop-out pill packaging, labels each pill with the day of the week. Currently Watkins, 56, sorts her own medications into a week-long pill box to prevent mistakes.

Hospitals can also help reduce medication errors by using new technology. One device called a smart intravenous pump stops nurses from inadvertently administering too much medication through an IV.

The report also recommends that doctors' offices and hospitals use electronic prescribing tools in an effort to prevent errors. Not only do the computer programs eliminate the problem of difficult-to-read penmanship, but they also prevent doctors from prescribing medications that interact badly with each other. "There are too many drug interactions to remember," said Dr. David Bates, an internist at Harvard Medical School and a researcher in drug safety.

Potential for Huge Reduction in Medical Errors

Electronic prescribing tools decrease the rate of medication errors by about 80 percent in the hospital setting, Bates said, citing results of a study he conducted. If implemented, electronic prescription writing could make a large impact in reducing medication errors, said Bates, who also contributed to the report. He estimates that 15 percent of U.S. hospitals are already using such systems.

"Doctors are converting as fast as they can," said Brooks, "but society needs to make a [funding] commitment." Brooks said setting up computerized medical and prescription records can cost thousands of dollars and can be prohibitively expensive for some doctors to shoulder on their own.

The Institute of Medicine, a branch of the National Academy of Sciences, is an independent organization chartered by Congress to advise the government on scientific matters. While the institute provides recommendations, it is ultimately up to the health care community to make the changes.

The last IOM report on medication errors written in 1999 resulted in few changes, said Inlander. But, he said, "I'm far more optimistic now, although I'm also realistic. I know that the health care system can move as slow as a snail."