MISTAKES MADE WITH MEDICINES : NO U.S. LAW REQUIRES INCIDENTS BE REPORTED.

Byline: Tony Saavedra The Orange County Register

Someone will die today from medication error, experts estimate.

But few will find out the cause of death.

That's because there are no federal laws requiring hospitals, pharmacies and clinics to report medication mistakes, even when the patient dies. Only a few states have a mandatory reporting system.

In California, doctors are required to report ``unusual incidents'' to the state Department of Health Services. ``Unfortunately, usually it's the hospital that sets its own definition (of unusual incidents),'' said Scott Lewis, department spokesman.

The tip of the iceberg can be seen in a voluntary study by the U.S. Pharmacopeia, a private group that advises federal regulators. The group found 350 medication errors nationwide - 15 of them fatal - during a recent 11-month period. Other studies, however, indicate the problem is far greater.

In California alone, the state Pharmacy Board investigated 563 complaints of medication errors in pharmacies and hospitals during the past three years. Nearly 400 were substantiated.

``It's a very serious problem because it is totally preventable, and we know there are several hundred deaths,'' said Michael Cohen, a pharmacist and president of the Pennsylvania-based Institute for Safe Medication Practices.

The Pharmacopeia group, along with Cohen's agency, last year helped form the National Coordinating Council for Medication Error Reporting and Prevention.

Several medical studies have found that a common problem is miscalculating dosages, misplacing decimal points and misreading zeros.

Drug names can also be confusing. In fact, hydralazine - the blood-pressure drug given to Steven Selby, a cancer patient who received an overdose - is sometimes confused with hydroxyzine, an antihistamine, experts say.

Other examples of problems involving misread decimals and zeros:

In 1983, a nurse gave a man 2.5 milligrams of the powerful sedative Halcion, when his prescription called for 0.25 milligrams. The patient slipped into a coma and died.

A 6-year-old boy recently died after being given a 120-milliliter dose of chloral hydrate syrup to sedate him before a CAT scan. The doctor had prescribed 12 milliliters, according to the Institute for Safe Medication.

A dermatologist prescribed a 0.1 percent solution of methoxsalen, which helps return the pigment to skin when used with an ultraviolet light. But the patient was given a 1 percent solution, resulting in a severe sunburn.

``You certainly set up so these types of things get caught, but as with any human process, there will be things that aren't caught,'' said Susan Winckler of the American Pharmaceutical Association. ``Often it is caused by a system; there's an overall system problem that needs to be addressed.''