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Your Rights As a Hospital Patient Questions to Prepare for Surgery If You Think You're Leaving the Hospital Too Soon Getting to Know Your MCO (managed care organization) Preventing Prescription Errors
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PREVENTING PRESCRIPTION ERRORS
Consumer Tips To Help Protect Against Prescription Errors |
Moreover, the report stated that medication errors result in "about 7,000 deaths" each year. The IoM argued that prescription errors are rising dramatically; there has been a more than 2-fold increase in deaths from prescription errors between 1983 and 1993. The IoM found that the greatest rise in prescription errors occurred outside of hospitals. The IoM argued that there had been a nearly 8_-fold increase in the number of outpatient deaths from medication errors, compared with a 2.3-fold increase in hospital fatalities due to prescription mistakes. In its report, the IoM cited the incredible number of prescription errors that occur outside of the hospital. The IoM stated "In a recent investigation of pharmacists, the Massachusetts State Board of Registration estimated that 2.4 million prescriptions are filled improperly each year in Massachusetts. Eighty-eight percent of the errors involved giving patients the wrong drug or the wrong strength." The Massachusetts report is consistent with other national studies. According to the national expert on medication errors, Pharmacist Michael R. Cohen, between 1.5% and 4% of all prescriptions are wrong and the mistake poses a substantial risk to the patient. A study published in the American Journal of Hospital Pharmacists found that 12.5% of all outpatient prescriptions contained errors and that 1.6% were "considered potentially dangerous." One of two additional studies estimated that 1.5% of all prescriptions were "potentially serious;" the other found a higher rate of 4% of serious medication errors outside of the hospital. Researchers have also found that children are the most vulnerable to medication errors. According to the IoM "Children are at particular risk of medication errors" and were twice as likely as adults to suffer from a prescription error. A recently published review found even more troubling statistics. According to a report in the Journal of the American Medical Association, "Medication errors were common in pediatric in-patient settings" and that children were three times more likely to experience a potentially serious prescription error than were adults. In addition to children, the elderly (who take the most medications per capita), and especially those elderly who reside in nursing homes, is another vulnerable population. According to the IoM, "For every dollar spent on drugs in nursing facilities, $1.33 is consumed in the treatment of drug-related morbidity and mortalityŠ" Unfortunately, these numbers may be only the tip of the iceberg. The IoM study concluded "Current estimates of the incidence of medication errors are undoubtedly low because many errors go undocumented and unreported." We are concerned that far too many prescription drug dispensing errors go unreported, not only to state agencies but to the public as well. Using the most conservative error rate, we estimate that 3 million of the 200 million prescriptions written in New York are dispensed incorrectly and pose a potential threat to the health of patients. (An estimate comparable with the Massachusetts study we cited earlier.) Moreover, using the IoM finding that over 7,000 Americans are killed due to prescription errors, we estimate that nearly 500 New Yorkers are killed each year due to medication dispensing errors, both inside and outside of hospitals. Despite the enormity of the threat to public health, New York State does little to address the problem. According to a recent analysis, only 27 pharmacists were punished by the State Education Department for prescription errors over the past four years. Moreover, while there is a requirement to report prescription drug dispensing errors that occur in hospitals to the state’s incident reporting program, there is no such requirement that pharmacies based outside of hospitals report such incidents. Thus, neither regulators nor the public know the true extent of the prescription error problem facing the state. When the IoM study was first published in 1999, New York’s top policymakers began a debate on how best to reduce medical errors. The State Health Commissioner publicly pledged her efforts to cut in half the number of hospitals’ medical errors by the year 2005. The Governor and the State Legislature enacted the "Patient Health Information and Quality Improvement Act of 2000" to broaden public accountability for physician, hospital, and HMO quality of care. However, nothing was done to increase state scrutiny of prescription dispensing practices. Each year, hundreds of New Yorkers are killed and thousands more have their health put at risk due to prescription mistakes. This is the year that New York State must take the next step in the effort to reduce the carnage caused by medical errors by embracing the following proposals: 1. All hospitals must establish an electronic system of prescription ordering and dispensing. It is simply not acceptable for 21st century hospitals to rely on a system handwritten notes—with all of the possible mistakes due to poor penmanship—to dispense potentially life-threatening medicines. The IoM has called for the virtual elimination of paper in the clinical setting by the year 2010. 2. All outpatient facilities—including all physicians’ offices—must also adopt electronic systems. The IoM noted that there has been a rapid rise in number of prescription errors occurring outside of the hospital. Clearly, the prevalent current system of pen and paper for office-based prescribing is inadequate, and too often dangerous, for New York patients. 3. All prescription mistakes must be reported to the state. The Health Department has stated that it is cracking down on hospitals that do not report medical mistakes—including prescription errors. Yet, inexcusably, there is no such requirement for reporting prescription errors to the Education Department or the Health Department in non-hospital settings. It is unconscionable to perpetuate this regulatory lapse—the state must mandate such a reporting requirement this year. 4. All prescription mistakes—and all medical mistakes—must be reported to patients and their families. The American Medical Association has stated that doctors must tell their patients when they make a medical error. As of this past January, the Joint Commission on Accrediting Healthcare Organizations (JCAHO)—the trade association that sets minimum quality standards for hospitals—has required all hospitals to tell patients when medical mistakes are made. While the new JCAHO requirement will extend to hospital pharmacies, it has no effect on outpatient pharmacies. We urge you to require that all health professionals, regardless of the setting that they practice in, tell their patients when medical mistakes are made. 5. The state must bolster its oversight of prescription writing and dispensing. Reports that only a handful of pharmacists are punished for prescription errors seems incredible given the estimated 3 million dispensing mistakes made each year. The State Education Department should re-evaluate the oversight of New York’s pharmacists and pharmacies and report to the public on its progress. Moreover, the SED must mandate that all accredited medical and pharmacy education programs include patient safety training as a core component. Consumer Tips To Help Protect Against Prescription Errors 1. Understand what drug they are being prescribed, in what dosage and for what condition. 2. Ask questions about the risks, expected side effects and interactions with other drugs. 3. Double check with the pharmacist that the prescription is the correct one for you. 4. Ask the pharmacist for a copy of the package insert and read any patient information that you receive carefully. If you believe that you, or a family member, has been subjected to a medical error related to the dispensing of a prescription drug, report it to the State Education Department’s Office of Professional Discipline at (518) 474-3817. You can also report to their web site at www.nysed.gov. and click on Office of the Professions. If you have a complaint about a doctor, call the Office of Professional Medical Conduct at (1 800 663-6114). Their web site is www.health.state.ny.us/opmc. Examples of Possible Prescription Mixups
DEADLY COMBINATIONS
SIMILAR NAMES
NAMES THAT CAN LOOK THE SAME WHEN WRITTEN BY HAND
DRUGS PLACED IN THE WRONG PLACE
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