Rampant drug errors in hospitals are preventable, study says.

Last July, 16-year-old Jasmine Gant died during induced labor after a nurse mistakenly infused her IV with an epidural anesthetic instead of penicillin at St. Mary's Hospital in Madison, Wisconsin. Gant is one of at least 1.5 million Americans who will be injured or killed this year--and every year--by preventable medication errors unless systems for prescribing and administering drugs are revamped, according to a recent report by the Institute of Medicine (IOM), a branch of the National Academy of Sciences.

These errors usually stem from health care practitioners' failure to ensure five "rights"--that the right patient receives the right drug, in the right dose, at the right time, and through the right route, said J. Lyle Bootman, dean of the University of Arizona College of Pharmacy and cochair of the IOM Committee on Identifying and Preventing Medication Errors, which produced the report.

"It's really erroneous to even estimate the number of deaths," Bootman added, describing the report's estimates as conservative due to a lack of standardized methods for documenting error-related deaths and reporting injuries caused by medication errors.

ATLA President Mike Eidson called the number of errors cited in the report "unnerving."

"Congress needs to focus on reducing medical errors instead of looking for ways to let negligent hospitals or penny-pinching insurance companies off the hook," he said. "The number of preventable medication errors shows just how important a strong civil justice system is to holding negligent corporations and individuals accountable."

On average, hospital patients are subject to one medication error per day of their stay, the study found, many of which are prescribing mistakes. Common prescribing errors include:

* use of the wrong drug name

* wrong dosage or administration instructions (for example, a physician misplaces a decimal point or indicates the wrong rate, frequency, unit of measure, or route of administration)

* failure to notice a patient's history of allergies or that information about allergies is missing from the record.

According to the study, medication errors occur for diverse reasons. Among them are:

* miscommunication among providers because of illegible handwriting on prescriptions and other written orders

* failure to check patient identification, so that a medication is administered to the wrong patient

* poor communication between health care providers and patients, leading to patient misunderstanding about how to properly take the medication or what precautions, if any, are necessary.

Implementing industrywide electronic prescriptions by 2010 and requiring standardized bar-coding systems for drug packages and patient identification bands were among the committee's proposed solutions, although Bootman noted that such changes will diminish errors only if hospitals implement them properly.

Before Gant died, St. Mary's Hospital had recently implemented bar coding of medications. Gant's nurse apparently failed to scan bar codes on the drug and on the patient identification band, which was in her medical chart and not on her wrist, where it should have been.

"This is different from [curing] cancer, where we're still trying to find the solution," Bootman said. "Here we have actual solutions, and it's just a matter of how dedicated we are to implementing [them.]"

Policy-makers in some states are requiring health care providers to make changes. The same month Gant died and IOM released its report, Illinois Gov. Rod Blagojevich signed an executive order creating a state Division of Patient Safety to standardize medication practices so that by 2011, health care providers statewide use electronic prescriptions. Medical errors cost Illinois $1.5 billion a year, Blagojevich said.

"If we're successful, our patient safety plan will save money because it will reduce the costs that come with treating medical errors. But far more importantly, it will save lives," he said in a statement.

The IOM concluded that each "adverse drug event"--the injury resulting from the medication error--adds about $8,750 to the cost of the patient's hospital stay. The total annual cost of the estimated 400,000 preventable drug-related injuries per year in hospitals is $3.5 billion, the report noted.

The full text of the IOM report, Preventing Medication Errors, is available online at http://darwin.nap.edu/books/0309101476/html.