Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually

Institute of Medicine Report Offers Comprehensive Strategies to Reduce Drug-Related Mistakes

August 4, 2006 – New York, NY– A report released July 20 by the Institute of Medicine on the toll and frequency of prescription drug errors urges everyone – from patients and educators to industry and regulators – to play a role in enhancing procedures and vigilance so that mistakes and subsequent costs to health and the economy can be reduced.

An IOM panel recommended strategies for preventing medication errors after canvassing scientific research evidence to analyze the problem and to find proven and promising solutions. National League for Nursing (NLN) Board of Governors’ secretary and professor at the University of Texas Health Science Center at San Antonio, Kathleen Stevens is one of two nurses who served on the 17- member panel of medication safety experts from across the nation. As director of the Academic Center for Evidence-Based Practice, Dr. Stevens participated in making evidence-based recommendations in the report during this 16-month study.

Medication errors are among the most common health care errors; 1.5 million injuries per year are caused by preventable prescription drug errors, including 400,000 a year in US hospitals. The report places a conservative estimate of $3.5 billion on costs associated with injuries.

“Every time we have a prescription filled, or one is filled for us, we put our faith in the system, that the prescription was filled properly and that it is what we need to help us recover from the illness or condition we face,” Dr. Stevens said. “This report is sobering, but it is the first step toward making a major dent in the issue of preventable prescription drug errors and their costs to society.”

Nurses and nurse educators have an essential part in preventing medication errors. “We need a comprehensive approach to reducing these errors that involves not just health care organizations and federal agencies, but the industry and consumers as well,” said panel co-chair Linda R. Cronenwett, the second nurse on the panel, and dean and professor, School of Nursing, University of North Carolina, Chapel Hill.

Recommendations include increasing communication across members of the health care team and incorporating patients as active partners in their own care. Patients will look to nurses to learn how to use recommended consumer-friendly information sources; and patient education skills will be even more essential in nursing education programs. Specific recommendations include:

• US health care providers must move away from paper-based prescriptions to the electronic prescribing of drugs by all providers by 2010.
• Advance nurse practitioners must exit their programs with the information technology skills for both order entry and for using automated decision support systems to detect possible medication interactions.
• FDA, AHRQ, and the pharmaceutical industry should collaborate with USP, ISMP, and other appropriate organizations to develop a plan to address the problems associated with drug naming, labeling, and packaging by the end of 2007.     

Should nurse educators develop a safety agenda for educational preparation of the nursing workforce? The IOM panel recommended that accrediting bodies responsible for oversight of professional education require more training in medication management practices and clinical pharmacology. To date, little is known about inclusion of safety in nursing education, beyond the “Five Rights.” The proposed health safety research agenda will require $100 million annually. Academic scientists have a high stake in determining effective approaches to teaching safety, increasing safety in care transitions, specialty ambulatory clinics, psychiatric care, and use of OTC and complementary and alternative medications.

The findings in this report have important implications for nursing education and the health care needs of this country,” said NLN CEO Dr. Ruth Corcoran. “The National League for Nursing is uniquely poised to advance the nation’s health care safety agenda through well targeted and excellent nursing education. Over the coming months, NLN leaders and members will develop goals and strategies to guide our profession and organization in being accountable to our consumers by addressing the recommendations advanced by the Institute of Medicine in this report.”

The full text of the report is available at www.nap.edu/catalog/11623.html.

Editors and reporters: For interview opportunities, please contact Karen R. Klestzick at 212-812-0376, kklestzick@nln.org.

Dedicated to excellence in nursing education, the National League for Nursing is the premier organization for nurse faculty and leaders in nursing education offering faculty development, networking opportunities, testing and assessment, nursing research grants, and public policy initiatives to its 18,000 individual and 1100 institutional members.