"Did You Know That Your Hospital Averages A Medical Error A Day for Every Patient?"

"The frequency of medication errors and preventable adverse drug events is cause for serious concern," said Linda Cronenwett, dean of the School of Nursing at the University of North Carolina at Chapel Hill , and co-chair of the panel that researched the information. She and other panel members said that the dilemma requires instantaneous action.

The errors the institute studied included doctors writing impossible to read prescriptions, nurses giving one patient medication intended for another, and a local pharmacist dispensing 100-milligram pills rather than the prescribed 50 milligrams.

The statement included the case of Betsy Lehman, a 39-year-old health reporter for the Boston Globe who died in 1994 after being given an incorrectly high dosage of an experimental chemotherapy agent. At least a quarter of the injuries caused by drug errors are avoidable, the report said.

The report did not deal with the equally controversial question of whether some drugs should be pulled from the market because of their inherent risks or whether the Food and Drug Administration does an sufficient job of ensuring that approved drugs are safe for general use. It also says that too many drugs have very similar names that are easy to confuse and that many medications would be better dispensed in blister packs that make it easier to recognize them and easier for consumers to remember whether they've already taken that day's dosage.

The report endorsed much wider use of electronic prescribing, which it says reduces errors. Inlander, president of the People's Medical Society, a Pennsylvania consumer health advocacy group, said that chain pharmacies have been "ahead of the pack" in adopting electronic prescribing.

The report's most conspicuous findings concerned errors in hospitals and long-term care facilities, which it said are generally not reported to patients or family members unless they result in injury or death. 

The panel said all health care organizations should report medication errors to patients whether they cause harm or not.

Based on existing studies, the panel anticipated that drug errors cause at least 400,000 preventable injuries and deaths in hospitals each year, more than 800,000 in nursing homes and facilities for the elderly, and 530,000 among Medicare recipients treated in outpatient clinics. Inlander said that the institute's panel sought information about how many people may have died as a result of drug errors, but said the estimates were so different -- from 7,000 to 50,000 a year -- that they were not included in the report.

The report also addresses the issue of errors of "omission" -- medications that patients should be getting but do not. Panel co-chair Lyle Bootman, of the University of Arizona's College of Pharmacy, said Wednesday that the panel believed those errors to be as widespread as other errors, but that researchers have not yet quantified the problem.

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