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Medication mix-ups: A deadly toll


It’s common knowledge that pharmaceuticals have provided humankind with almost miraculous benefits over the past century in their ability to prevent, cure or reduce the impact of disease and to prolong life. But serious errors in the way medicines are dispensed by pharmacies and self-administered by patients are taking a big and growing toll on patients’ well-being.

Adverse drug events related to dispensing errors, unforeseen drug interactions, dosing errors and other problems are killing thousands of Americans each year and costing the U.S. health system and economy tens of billions of dollars in additional acute care costs and lost productivity. One estimate from the Institute of Medicine of the National Academies said medication errors injure at least 1.5 million people a year and account for at least $3.5 billion in additional hospital costs alone each year for Medicare.

Concern over this patient safety reached a crescendo in late 1999 with the publication of “To Err Is Human,” a report from the IOM that attributed as many as 98,000 preventable deaths to medical errors each year. Those findings spurred new legislation and regulations, including passage in 2005 of the Patient Safety and Quality Improvement Act. The law directed the Department of Health and Human Services to establish “a framework by which hospitals, doctors and other healthcare providers may voluntarily report information to Patient Safety Organizations, on a privileged and confidential basis, for the aggregation and analysis of patient safety events,” according to the Government Accountability Office.

Compounding the problem, said Michael Cohen, president of the Institute for Safe Medication Practices, is the fact that “we are treating more patients and they are sicker to start with, so they don’t tolerate some of the errors that [occur].” In addition, he said, “many of the drugs we use today and the way we use them makes it more likely that harm will occur when errors happen.”

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