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News from the National Academies

Opening Statement

by

J. Lyle Bootman


Dean and Professor, University of Arizona College of Pharmacy; Founding and Executive Director, University of Arizona Center for Health Outcomes and Pharmaco Economic Research and Co-chair, Committee on Identifying and Preventing Medication Errors


Thank you, Harvey, and good morning everyone.  In 1999 the Institute of Medicine report To Err Is Human: Building a Safer Health System raised awareness about medical errors and accelerated efforts to prevent such mistakes.  The report we are releasing today makes clear that with regard to medication errors, we still have a long way to go.  The current process by which medications are prescribed, dispensed, administered, and monitored, is characterized by many serious problems that threaten both the safety and positive outcomes of patients.  Each of the steps in the process needs improvement and further study.


Here are two sobering statistics.  The committee estimated that on average, there is at least one medication error per hospital patient per day, with error rates varying widely across facilities.  In addition, the committee estimated that at least 1.5 million preventable drug-related injuries occur each year in U.S. hospitals, long-term care facilities, and outpatient clinics.


We have a very limited understanding of the costs associated with medication errors.  Assuming conservatively that 400,000 preventable drug-related injuries occur in hospitals each year, the committee estimated that these mistakes will generate extra medical costs of at least $3.5 billion in 2006.  One study that we reviewed found that medication-related injuries at outpatient clinics resulted in roughly $887 million of extra medical costs in 2000 -- and that study looked only at injuries experienced by Medicare recipients, a subset of clinic visitors.  The committee could find no studies on the costs of medication errors in long-term care facilities.


These figures significantly underestimate the overall cost to the nation of medication errors because of some important omissions:

  • First, the costs of some highly common medication errors, such as drug use without a medically valid indication and failure to receive drugs that should have been prescribed, were excluded from the study of Medicare patients in outpatient clinics that I just cited.  In addition, the costs of morbidity and mortality arising from the failure of patients to comply with prescribed medication regimens were not assessed.
  • Second, all of the studies that we looked at omitted some important costs, such as lost earnings, costs of not being able to carry out household duties, and compensation for pain and suffering.
  • Third, few data are available on the costs of medication errors that do not result in immediate harm, but may affect whether the patient achieves the desired outcome, such as lowered blood pressure.  While no injury is involved, these errors often create extra work, and the costs involved may be substantial.

Despite the lack of data on many interventions that might improve the quality and safety of medication use, the committee offers recommendations for change that should be implemented and evaluated.  People who take medications have a huge stake in this effort.  The most powerful strategy for improving safety and achieving desired clinical results may be motivating providers and organizations to support the full engagement of patients and their guardian in improving the safety and effectiveness of medication use.


The report provides consumers with a list of specific questions they should ask their health care providers, including how to take their medications properly and what to do if side effects occur or they miss doses.  The list also includes actions consumers should take, such as requesting that their providers give them a printed record of the drugs they have been prescribed.  The committee believes that patients should maintain an up-to-date list of all medications they use and share this list with all of their health care providers.  It should include over-the-counter products and dietary or herbal supplements in addition to prescription drugs, and it should note the reasons they are taking each product.  In addition, patients should note any drug and food allergies they have.


Health care providers and leaders of health care organizations must create the environment and infrastructure necessary to continuously learn about and improve the safety of all steps in the medication-use process.  Our report provides guidance on the type of error prevention strategies that should be implemented in each care setting.

New computerized systems for ordering therapies and other applications of information technology show promise for reducing the number of drug-related mistakes.  Studies indicate that paper-based prescribing is associated with high error rates.  Electronic prescribing is safer because it eliminates problems with handwriting legibility and, when combined with decision-support tools, automatically alerts prescribers to possible interactions, allergies, and other potential problems.  The committee recommended that by 2008 all health care providers should have plans in place to write prescriptions electronically.  By 2010, all health care providers should be using e-prescribing systems, and all pharmacies should be able to receive prescriptions electronically.

 

More generally, all health care organizations should seek to become highly reliable providers of care focused on improving medication safety and effectiveness.  To do this, they will need to routinely monitor for medication errors and adverse drug events.  Progress toward improved medication safety can be measured accurately only by knowing the actual incidence rates of errors and adverse events.

 

Prescribers often lack sufficient knowledge about how the drugs they are prescribing will work in specific patient populations.  If the balance of risks and benefits is not known -- as is common with children and the elderly -- it is difficult to say whether the medication is appropriate for the patient.  Improving medication use and reducing errors, therefore, requires improving the quality of information generated by the pharmaceutical industry and other researchers about drug products and their use in clinical practice.  We also need to better understand how to communicate such information effectively to clinicians and patients via packaging, leaflets, and health information technology systems.  And we need a better understanding of how to prevent medication errors in all care settings and in transitions between care settings.  In this report, we have proposed a research agenda for industry and government that can help meet these critical needs.


The American people expect and deserve safe and effective medication care.  Our committee has developed an ambitious agenda for making the use of medications safer and ensuring that patients experience the desired clinical results.  This agenda requires that all stakeholders -- patients, health care providers, payers, industry, and government -- commit to working together to prevent medication errors.  Given that a large proportion of injurious drug events are preventable, this proposed agenda should deliver early and measurable benefits.


Now, my colleagues Wilson Pace and Albert Wu and I will be pleased to take your questions.  As a reminder, we ask you to state your name and affiliation before asking your question. Thank you.