Introduction to Medical Errors
The US Center for Disease Control and Prevention estimated that annual hospital-acquired infections in the US number over 2 million, resulting in 90,000 deaths a year and $4.5 billion in excess healthcare costs. The research shows a range of cost estimates, some suggesting excess costs may be two to four times that amount. In long-term care facilities, the CDC estimates an additional 1.5 million health-care associated infections occur each year. Medical Errors are the eighth leading cause of death in our country.More people die from medical errors than from vehicle accidents (43,000), breast cancer (42,000) or from AIDS (16,000) per year.These figures don't include deaths from medical errors that happen in outpatient, long-term care, home-health care, or doctor's offices. Since 1992, the Food and Drug Administration has received about 20,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher.
There is no "typical" medication error, and health professionals, patients, and their families are all involved. Some examples:
A physician ordered a 260-milligram preparation of Taxol for a patient, but the pharmacist prepared 260 milligrams of Taxotere instead. Both are chemotherapy drugs used for different types of cancer and with different recommended doses. The patient died several days later, though the death couldn't be linked to the error because the patient was already severely ill.
An elderly patient with rheumatoid arthritis died after receiving an overdose of methotrexate--a 10-milligram daily dose of the drug rather than the intended 10-milligram weekly dose. Some dosing mix-ups have occurred because daily dosing of methotrexate is typically used to treat people with cancer, while low weekly doses of the drug have been prescribed for other conditions, such as arthritis, asthma, and inflammatory bowel disease.
One patient died because 20 units of insulin was abbreviated as "20 U," but the "U" was mistaken for a "zero." As a result, a dose of 200 units of insulin was accidentally injected.
A man died after his wife mistakenly applied six transdermal patches to his skin at one time. The multiple patches delivered an overdose of the narcotic pain medicine fentanyl through his skin.
A patient developed a fatal hemorrhage when given another patient's prescription for the blood thinner warfarin.
These and other medication errors reported to the FDA may stem from poor communication, misinterpreted handwriting, drug name confusion, lack of employee knowledge, and lack of patient understanding about a drug's directions. "But it's important to recognize that such errors are due to multiple factors in a complex medical system," says Paul Seligman, M.D., director of the FDA's Office of Pharmacoepidemiology and Statistical Science. "In most cases, medication errors can't be blamed on a single person."
A medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer," according to the National Coordinating Council for Medication Error Reporting and Prevention. The council, a group of more than 20 national organizations, including the FDA, examines and evaluates medication errors and recommends strategies for error prevention.
