/publications/issue/2006/2006-09/2006-09-5839

Reducing Medication Errors to Save Lives

Author: 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 they—along with pharmacies—should 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.