Wrong Dosages administered daily
The Philadelphia Inquirer
July 21, 2006

A new report says that hospital patients fall victim to medication mistakes every day.
By: Dawn Fallik

From simple mix-ups to fatal overdoses, medication mistakes happen, on average, once a day to every hospital patient, a new report says.

Nationwide, at least 1.5 million people annually are harmed from drug errors, more than half of them in nursing homes, said the Institute of Medicine report, released yesterday.

The total financial cost? More than $3.5 billion in extra lab fees, increased hospital stays, and more drugs needed to fix what went wrong.

"I'm a patient-safety researcher, and I was surprised and shocked at just how common and how serious this is," said Albert Wu, professor of health policy at John Hopkins University, who helped write the report.

"We need to wake up and take this more seriously, and then everyone can play a part."

The report is a follow-up to the 1999 "To Err Is Human" review, also by the Institute of Medicine, that found that 7,000 people die every year from medication errors. That's about one for every hospital in the country - a number experts consider low.

The report was based on a review of a number of studies, ranging from medication-error costs to drug-labeling standards.

In the hospital, many mistakes occurred with specific drugs, mainly blood thinners and insulin, complicated medications that have adverse reactions to other drugs.

The original "To Err Is Human" report was triggered by the case of Betsy Lehman, 39, who died after receiving an overdose of a chemotherapy drug to treat breast cancer. She was a health reporter for the Boston Globe.

But almost everyone interviewed for this article also had a personal story to tell.

David Bates, chief of internal medicine at Brigham and Women's Hospital in Boston, said his daughter had been prescribed too much of a painkiller before surgery. The mistake was caught.

Lawrence Carey, a pharmacist at Thomas Jefferson University Hospital and a Philadelphia University professor, said he stopped a pump that had been programmed to deliver into his body a day's worth of a blood thinner in 15 minutes.

James Bagian, chief patient-safety officer for the Department of Veterans Affairs, said his father was paralyzed for more than a year because of an overdose. He said consumers needed to be vigilant.

"If you don't care about your health care, who does?" asked Bagian, known for implementing innovative electronic prescribing and bar-coding programs at the VA.

"It's like buying a car," he said. "Anyone who goes into the healthcare system without some level of skepticism is just foolish." The Institute of Medicine panel laid blame across the healthcare system, from government officials to people in waiting rooms. The Washington-based independent panel made several recommendations"

• The Food and Drug Administration should make drug evaluations more comprehensive, referring to safety problems involving hormone-replacement therapy, COX-2 inhibitors, and nonsteroidal anti-inflammatory drugs.
• Hospitals should incorporate electronic prescribing, with doctors and pharmacies moving to e-scribing by 2010.
• Patients should pay more attention to their medication directions and be assertive in asking questions about risks.
• Medical, pharmacy and nursing schools should teach basic safety protocols as soon as students step in the door.

"There are medical abbreviations that should never be used, that are often misunderstood, and students should be learning this immediately." Said Michael Cohen, president of the Institute for Safe Medication Practices, an independent watchdog group in Huntingdon Valley.

Cohen, who has criticized pharmaceutical companies for creating confusing medication labels and drug names, was on the Institute of Medicine panel.

Locally some of the report's proposals are already in place. In the Philadelphia region, more than 20 percent of hospitals have e-scribing, or Computerized Physician Order Entry, said Andrew Wigglesworth, president of the Delaware Valley Healthcare Council, which represents 130 health-care organizations in the region.

Several hospitals have instituted bar-coding systems in their pharmacies, and some, such as Methodist Hospital, have bar codes on both patient's wristband and their medications. So if a nurse scans a medication and a wristband, they should match.

Of course, the technology is neither cheap nor foolproof. The Hospital of the University of Pennsylvania spent $6 million in 2004 to install a physician-order entry program. It greatly reduced handwriting errors, but not all human ones, said Patrick J. Brennan, Penn's chief medical officer.

"If the information is displayed in a way that the doctors and nurses are not accustomed to, that's a new fact and can lead to unintended errors," he said. For example, if a drug prescription is for 40 mg, but the computer only displays the unit 20 mg, a patient might receive too low a dose, he said.

One problem is that software is not standardized, said Bagian, of the VA. That means if a patient who lives in Nebraska has a car accident in Philadelphia, the hospital might not be able to pull up his records. Even regional systems do not always share information.

"We're not integrated in this playing field yet," said Peter Pronovost, medical director of the Center for Innovation in Quality Patient Care at John Hopkins. "We can put bar codes in and smart pumps, but we don't have the whole system working together all the way through."

With all the technology, warnings and information, the first step toward eliminating mistakes starts at the simplest level, with patients knowing - and telling - their doctors all the medications they take. That includes over-the-counter drugs, herbal supplements, and vitamins, said Charles Inlander, a consumer advocate in Allentown who was on the Institute of Medicine panel. "Physicians have medical errors made on them just like the general public," said Inlander, retired president of the People's Medical Society. "We're all second-class citizens when it comes to health care."