Fred M. Eckel, RPh, MS; Pharmacy Times Editor-in-Chief
Medication errors have been
around at least as long as
doctors have been scribbling
prescriptions. Once in a while, however,
something sheds new light on the
disturbing scale and importance of
the problem.
One such event was the publication of
the Institute of Medicine's (IOM) latest
report, Preventing Medication Errors.
Among the startling statistics in the
report: 1.5 million Americans are harmed
by preventable adverse drug events each
year, and hospitalized patients suffer an
average of 1 medication error per day.
What is the cost? Treating injuries caused
by these errors costs more than $3.5 billion
a year in hospitals alone, according to
the report.
Most medication errors do not occur
in the pharmacy. They occur when prescriptions
are written or when drugs are
taken by the patient. We are all human,
however, and humans make mistakes.As
the report points out, small errors can
result in catastrophe. And for many of us,
growing prescription workloads and an
increasingly stressful business environment
add to the likelihood of making
those mistakes.
This is why it is worth looking closely at
ways to help eliminate errors at any stage
of the process. Quality-management software
is available from various sources,
including the National Association of State
Pharmacy Associations, and many companies
have already taken steps to implement
these tools.
In addition, the IOM describes pharmacy
medication information leaflets as
"inadequately designed to facilitate consumers'
ability to read, comprehend, and
act on medication information" and
notes that they vary in quality from one
pharmacy to another. It recommends
that government agencies standardize
the format of leaflets so that the information
is useful to consumers.
Tools that reduce the need for data
entry can have a powerful effect in
reducing errors. The IOM's report recommends
that prescribing organizations
establish plans for electronic prescribing
(e-prescribing) systems by 2008, and
that theyalong with pharmaciesshould implement the plans by 2010. E-prescribing
has been slow to take off,
but momentum has built steadily over
the past few years and is being spurred
by use in Medicare and by proposed legislation.
It is time to recognize that e-prescribing
is a reality and to shed any lingering
reluctance to use it. Adopting
technology often involves extra cost and
effort, but e-prescribing may deliver a
big benefit: If it can reduce drug errors, it
can save lives.
Mr. Eckel is professor and director of
the Office of Practice Development
and Education at the School of
Pharmacy, University of North
Carolina at Chapel Hill.