Despite many years attempting to make medications safer, the Food and Drug Administration (FDA) claims medication errors kill at least one person a day and injure about 1.3 million people each year in the United States. New efforts are now under way to inform the public about the problem and provide guidance to prevent an error from occurring. The American Society of Health-System Pharmacists and the Institute for Safe Medical Practices (ISMP), a non-profit organization certified by the federal government to collect error reports and other information regarding quality breaches, is launching a new National Alert Network for Serious Medication Errors. This system will notify 35,000 healthcare professionals, such as pharmacists, doctors and nurses, when a dangerous or life-threatening issue is reported to the ISMP. The two organizations also hope to extend this network to about twenty-six organizations that work to promote safe medication use. The hope is that the system will cause these healthcare professionals to be more aware in order to prevent future mistakes; the same mistake should never happen again.
The system comes at a critical period when hospitals are being pressured to cut costs and stretch staff for as long as they can possibly work because of the poor economy; this may be fueling the increase in medication mistakes. In November, ISMP conducted a survey in which almost half of the 820 respondents, predominately nurses and pharmacists, reported a large or moderate negative impact on medication safety within the hospital due to the economy. In fact, 20% reported mistakes involving the most dangerous medications, such as insulin, heparin, chemotherapy and narcotics. It is not only wrong dosages or a wrong concentration that can hurt a patient but a mistake in the way the drug is administered as well.
The new system already worked well in its test run stage after alerting doctors that the concentration of iron in Mead Johnson’s Fer-In-Sol oral infant iron drops had been reduced; after the reduction some doctors had been prescribing too low of a dose even though there were labels on the drug explaining the change. Experts also believe some causes of medication error are the doctor’s poor handwriting, drug names sounding too familiar, and drug labels looking similar (as in the case of heparin). While the new system does seem to be a step in the right direction, many believe policy makers and hospital executives, who are slow to adopt new technologies such as computerized medical records, need to make these changes in order to ensure there are fewer errors. For example, if the medical records and prescriptions are computerized, a doctor’s illegible handwriting would not be an issue.
Consumers are able to sign up for customized reports about certain medications and allowed to submit a report regarding any problems with their medications at the ISMP’s www.consumermedsafety.org. They are also able to submit any medication errors to the FDA at fda.gov/safety/medwatch. Patients and family members should also ask the medical staff what medications are being given and to confirm that the correct dosages are being administered properly.
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