Medication slip-ups lead to more deaths, research study shows.

The shift toward managed health care--with its growing reliance on outpatient treatment--is having an increasingly deadly effect on Americans, according to a team of University of California researchers in San Diego.

The overall number of deaths from medication errors---when a doctor prescribes the wrong dose or type of medicine, for example--more than doubled between 1983 and 1993 (2,876 deaths to 7,391), said David Phillips, a mortality expert and sociologist, in a study published in the February 28 issue of the British medical journal The Lancet.

Phillips, quoting statistics compiled by the American Hospital Association, noted that the number of outpatient visits for medical care increased by 75 percent, and the number of days patients spent in the hospital fell by 21 percent.

"The shift to outpatient treatment implies that more medications are taken with the patient, not medical personnel, exercising quality control," he said. He added that treating more people on an outpatient basis makes it "increasingly difficult" for physicians to maintain quality relationships with their patients.

The study is based on the examination of U.S. death certificates from 1983 to 1993 in which the cause of death was "officially acknowledged" as accidental medication errors made by patients or by medical personnel.

Phillips said the results of the UC-San Diego study bore out the research team's premise that if the increase in medication error deaths could be tied to a shift to increased outpatient care, then the increase should be steeper for outpatients.

Breaking down the number of medication error deaths into outpatient and inpatient categories, Phillips said death rates increased for both, but that the "increase was especially marked for outpatients." Outpatient deaths increased eightfold between 1983 and 1993, and inpatient deaths more than doubled.

Phillips also referred in the study to the "risk ratio" of medication error deaths. He said that 1 in every 539 outpatient deaths in 1983 was caused by medication errors versus 1 in 1,622 inpatient deaths during that year. That means outpatients were three times likelier than inpatients to die from these errors.

By 1993, 1 in 131 outpatient deaths and 1 in 854 inpatient deaths were caused by medication errors, meaning that outpatients were 6.5 times likelier than inpatients to die.

"The proportion of deaths from medication errors has always been particularly large for outpatients, and this proportion has increased markedly in recent years," Phillips said.

The study showed that increasing numbers of errors were made in prescribing opiate drugs and drugs for the central and autonomic nervous systems.

The study also broke down increases in medical errors by patients' race and gender. African American males showed the largest increase (5.23-fold), followed by white males (2.8-fold), African American females (2.27-fold), and white females (1.53-fold). "The high-risk groups may be those most likely to receive outpatient treatment," Phillips said.

Fending off possible refutations of the study results, Phillips said the increase in deaths cannot be accounted for by increases in prescriptions written. Quoting statistics from his study and one by IMS America, a health care consultant in Plymouth Meeting, Pennsylvania, he said that medication error deaths increased more than twofold between 1983 and 1993 while the number of prescriptions increased only slightly (1.39-fold) during that time.

"Medical personnel may need to compensate for changes in medical care by increased vigilance in the delivery and monitoring of medications, especially for outpatients," Phillips said.