Preventing Medication Errors:
Safe Medication Use is Achievable and Affordable
Chareese W. Brown
HTHC 523-201: Winter 2012
January 17, 2012
Almost everyone will take prescription and non-prescription medication. It is estimated that 82% of United States (U.S.) adults will use prescription medicines, over-the-counter remedies, and/or dietary/herbal supplements. Nearly one-third will use five or more different medications (citation). Most of the times these medications are advantageous, however on occasion can cause an adverse drug event (ADE) to the person taking them. ADEs are a serious public health problem. An ADE is an injury caused by the use of a drug. The injury can result from an adverse drug reaction or overdose. It can also be caused by the use of the drug from a dose reduction or discontinuation of drug therapy (citation). Given the number of medications taken, medication-related injuries may appear unavoidable. However, ADEs due to errors in prescribing, distributing, and administering are preventable (IOM, 2006). Research on the cost and causes of ADEs has been reported for years in medical literature. A publication by the Institute of Medicine (IOM): To Err Is Human: Building a Safer Health System brought public attention to the issue of medication errors. The report identified a quality problem in the U.S. health system as a contributing factor. The decentralized and disintegrated nature of the U.S. health system is challenged with opportunities for mistakes to occur. Under these circumstances, the Centers for Medicare and Medicaid Services requested that the IOM study the frequency of preventable medication errors and formulate a national agenda for reducing these errors. The resulting report, Preventing Medication Errors, found that they are quite common and costly. In hospitals, medication errors are common during every step of the process from procuring and prescribing to administering and monitoring the impact of the drug. Unfortunately, these errors most frequently occur during the prescribing and administering phases. A patient can potentially be exposed to more than one medication error each day. There are significant differences in error rates found across health care facilities. It is difficult to obtain accurate measurements of how often preventable ADEs occur. One study estimated that 380,000 preventable ADEs occur each year in hospitals, another estimated 450,000. In other health settings, the numbers are equally troubling. It is estimated that 800,000 preventable ADEs occur each year in long-term care facilities. Another study found that 530,000 preventable ADEs occur each year among outpatient Medicare patients and suggests that these numbers are likely to be underreported. Additionally, none of these studies included measurements for errors of omission (failures to prescribe medication when it should be). Taking all of these statistics into consideration, the IOM concluded that at a minimum there are 1.5 million preventable ADEs that occur in the U.S. each year. The true number possibly will be more. Undoubtedly, medication errors are costly to patients, their families, their employers, and to hospitals, health care providers, and insurance companies. However, there are limited reliable estimates of these costs. One study found that each preventable ADE that occurred in a hospital added approximately $8,750 to the cost of the hospital stay. Assuming 400,000 of these events each year—a conservative estimate— the total annual cost would be $3.5 billion in this one group. Another study looked at preventable ADEs in Medicare recipients and found an annual cost of $887 million for treating medication errors in this group. Unfortunately, these studies cover only some of the medication errors that occur each year in the U.S. and only reviewed some of the costs and do not include costs for lost...