Medication Errors Fact Sheet

There is a concerning threat within the medical system. It kills more people in the United States than breast cancer or AIDS, claiming between 44,000 and 98,0001 lives each year. It is estimated to cost between $17 billion and $29 billion2 per year in hospitals nationwide. And, despite being one of the leading causes of death and injury in the United States, most people believe they are safe from the reach of this dangerous condition. It is not an emerging pathogen or virus -- its medical error. There is a growing body of evidence that demonstrates the breadth of this pressing issue. And, while there are national patient safety standards and clinical guidelines that are being implemented, the issue is still a significant concern. According to one study, the average intensive care unit patient experienced almost two errors per day, which translates to an accuracy level of approximately 99 percent. One out of five of these errors was potentially serious or fatal. If performance levels of 99.9 percent, a substantially higher rate than found in the ICU study, applied to the airline and banking industries, it would equate to two dangerous landings per day at O'Hare International Airport and 32,000 checks deducted from the wrong account per hour3. While the issue of patient safety received heightened attention following the 2000 report, To Err is Human: Building a Safer Health System, issued by the Institute of Medicine (IOM), medical errors, and specifically errors in the medication process, continue to plague healthcare providers. Addressing Errors Where They Matter Most Medication errors can occur at any point in the medication delivery process starting with a physicians prescription, during pharmacy transcription and compounding and at the patients bedside, the last chance for errors to be caught prior to dispensing by a nurse. (see chart below4).

Where Errors Occur

Physician Prescribing: 39 % Pharmacy Transcribing: 12% Compounding: 11% Point of Care/Bedside

Administering: 38%

Kohn, Linda et al. To Err is Human: Building a Safer Health System, Washington, D.C: INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS: 2000. 2 Kohn, Linda et al. 2000. 3 Leape LL. Error in medicine. JAMA 1994; 272:1851-57. 4 Leape et al. JAMA, July 5, 1995.

A 1995 study published in the Journal of American Medical Association (JAMA) found that only two percent of the errors that occur during the medication administration process are intercepted5.
Medication Error -- Fast Facts A medication error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim6. Experts believe that for each serious adverse event, there are probably dozens of near misses. More people die from medical errors than from workplace injuries7. Medication errors account for approximately one out of 131 outpatient deaths and one out of 854 inpatient deaths.8 According to MEDMARX, the anonymous national medication error reporting database operated by the United States Pharmacopeia (USP), 55 percent of fatal hospital medication errors reported involved seniors9. The Wall Street Journal reports that an estimated five percent of U.S. hospitals have implemented computer-based bar-coding systems, while an additional 17 percent plan to implement by 200510.

A 2002 study issued by the USP, which evaluated medication errors compiled from 482 hospitals and health care facilities in the U.S., found nearly 200,000 medication errors during 2002. While the vast majority of the errors were corrected before causing harm to the patient, more than 3,000 errors, or 1.7 percent resulted in patient injury. According to the report, when harm occurred, the wrong route and the wrong administration technique were the second and third most common errors. Additionally, health care facilities attributed medication errors to a wide variety of reasons, often citing workplace distractions, staffing issues such as shift changes and floating staff, and workload increases as contributing factors11.

6 7

Kohn, Linda et al. 2000. Kohn, Linda et al. 2000. 8 Kohn, Linda et al. 9 The United States Pharmacopeia. Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality. 2002. 10 Armstrong D., Study Finds Increase in Medication Errors at U.S. Hospitals, The Wall Street Journal, November 18, 2003. 11 The United States Pharmacopeia. Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality. 2002.

Although some progress has been made in adopting new technology such as bar-coding systems that help clinicians improve standards in medication management, most U.S hospitals have been slow to implement this technology. To date, just five percent of hospitals in the United States have implemented computerized bar-coding technology, while the majority continues to rely largely on human intuition and paper-based systems. Implementing Solutions for Improvement Most medication errors are caused not by individual carelessness, but rather by faulty processes or conditions that lead people to make mistakes or fail to prevent them. Developing and adopting new standards across all areas of the health system from doctors offices and hospitals, to clinics and nursing homes is the best way to achieve error mitigation. While there is no silver-bullet solution to the problem of patient safety and medical error, there are national standards and clinical guidelines and processes that are being implemented to address the challenges faced by the health care industry. And, with the help of dedicated organizations that are working to elevate awareness of the issue and to develop solutions that improve patient safety, the industry will see improvements that will translate into enhanced patient care. Following is a list of organizations and associations driving toward creating solutions to this pressing issue: The Institute of Medicine (IOM) The United States Pharmacopeia (USP) The Institute for Safe Medical Practices (ISMP) The National Quality Forum (NQF) The National Patient Safety Foundation (NPSF) The Agency for Healthcare Research and Quality (AHRQ) The Quality Interagency Coordination Task Force (QuIC) The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) The Leapfrog Group

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