Six years ago the National Institute of Medicine made headlines when it estimated that medical mistakes kill as many as 98,000 American hospital patients each year.
Now, at the behest of Congress, the Institute has followed up with a report specifically on medication errors — the most frequent kind of medical mistake.
After nearly two years of study, the Institute's experts estimate — conservatively — that 1.5 million Americans are harmed every year by medication mistakes.
They take place every day in hospitals, clinics, doctor's offices, nursing homes and pharmacies. The report says they cost society at least $3.5 billion a year.
Experts say they already know how to prevent many medication errors.
One way is through computerized prescribing systems such as the one at Dana Farber Cancer Institute in Boston. It was here, almost a dozen years ago, that two medication errors shook the medical world. A chemotherapy overdose killed Betsey Lehman, a Boston Globe health columnist, and damaged the heart of schoolteacher Maureen Bateman.
That episode is credited by many as launching the error-prevention movement. It was mentioned in the first sentence of the 2000 Institute of Medicine report and is featured again in the new report.
Now all chemotherapy orders are filled by computer. There's no paper, no illegible handwriting, no miscalculation of dosage. Sylvia Bartel, Dana Farber's chief pharmacist, demonstrates the new program by ordering a cancer drug for a fictitious patient named Edwina. The computer says the correct dose for a woman of her weight and height is 25 millligrams.
"Let's put in 50 milligrams," Bartel says. The computer bings. "It says I may not increase the dose for non-exception chemotherapy orders beyond the original dose. So I just can't."
Computer prescribing by itself doesn't make overdoses a thing of the past, says Jim Conway, an author of the Institute of Medicine report and, until last year, a top Dana Farber executive.
"Could we say it could never happen? No," Conways says. "Could we say that we know of no better systems in the country to support safe practice? Absolutely!"
But fewer than 10 percent of U.S. hospitals have computerized prescribing systems. The rest still use paper-based systems that are prone to error.
The new report says on average, a hospital patient is subject to at least one medication error every day he or she is in the hospital.
Michael Cohen is another author of the new report. He's president of the Institute for Safe Medication Practices. He says bar-coding every dose of drug and matching it to a code on patients' wristbands can also prevent mistakes. But Cohen says only one hospital in seven uses bar-coding.
Cohen recently visited a hospital that does.
"This was interesting," he says. "In a one-month period, there were 74 times when a nurse walked into the wrong patient's room, scanned the patient's wrist band, and was alerted to the fact that they were not with the right patient. That's an amazing number of people that may have gotten the drug that wasn't intended for them!"
The Institute of Medicine panel wants hospitals to have plans to computerize their prescribing systems by 2008 and to start using them by 2010. By then, it says, pharmacies should also be able to receive electronic prescriptions.
The report has plenty of advice for others. For instance, it says the drug industry and the Food and Drug Administration should clean up the confusion of look-alike and sound-alike drug names and simplify labels and packages.
A large part of the new report is aimed at consumers. Charles Inlander was the consumer representative on the panel. He's president of the People's Medical Society.
Inlander says patients should be inquisitive in the doctor's office, at the pharmacy, and in the hospital.
"In the hospital, we advise patients or their surrogates — their family member or friend — to ask the doctor or nurse what drugs they're being given in the hospital and to give them that in writing. To not take a drug unless they're being told what the purpose of that drug is for. Prior to surgery, you should ask if there are any medications that you should take or any medications you should stop taking before surgery. Most patients are not told either of those."
But change is slow. Boston safety expert Jim Conway says often decision-makers get moving only when something bad happens — to them.
"I have certainly found organizations that are doing amazing work. And when you go looking for the 'why' you find a tragedy."
The exact number of tragedies is still unknown. The Institute panel estimated the number of patients who are harmed by medication mistakes. But they say there are no good data on how many actually die from these errors.