Reducing drug errors: IOM issues call to action

The Institute of Medicine (IOM) recently released Preventing Medication Errors, a 544-page report that is the fourth in its Quality Chasm series. The authors concluded that medication errors harm at least 1.5 million people per year in the United States. In addition, the cost of treating drug-related injuries that occur in hospitals alone conservatively amounts to $3.5 billion per year, according to the Committee on Identifying and Preventing Medication Errors, which wrote the report. The report was funded by the Department of Health & Human Services and the Centers for Medicare & Medicaid Services.

Eric Cannon, Pharm.D., a member of the committee and director of pharmacy services and health and wellness at SelectHealth/Intermountain Healthcare in Salt Lake City, agreed. "Throughout the report, the one thing the committee kept coming back to was the need for the greater involvement of patients in their own care," he said. "Pharmacists can have the greatest impact on the incidence of medication errors by increasing their patients' involvement in the therapeutic process. A discussion of medication therapy with the patient, whether in the community or hospital setting, is an opportunity to catch a lot of medication errors."

Pharmacists must also involve other healthcare professionals in addressing the issue of medication errors. "This report issues a challenge to the pharmacy profession in terms of collaboration with medicine and nursing," Bootman said. "Solving this problem is not just a pharmacy initiative."

Bootman continued by mentioning that the report proposes that by 2008, all healthcare delivery systems should have plans in place to write Rxs electronically and that by 2010, all providers should be using e-prescribing systems and all pharmacies should be able to receive prescriptions electronically. He noted that this will require the collaboration of government at the state and federal levels with healthcare systems, providers, and state boards of pharmacy, medicine, and nursing.

Said Kasey Thompson, Pharm.D., director of the practice standards and quality division and patient safety at ASHP, "The report describes the need for a coordinated, interdisciplinary, team-based care model, in which healthcare professionals, patients, and family members work together to ensure that there is high-quality medication therapy management."

Thompson said that interdisciplinary team-based models should be applied across the continuum of care, and not just in hospitals. In addition, he said that fundamental changes in healthcare professional education are needed to ensure that those who need to work in teams are educated and trained as teams.

Another committee recommendation that will require interprofessional collaboration is that further research be done to identify cost-effective ways of reducing the incidence of medication errors, said Bootman, who also advised the profession to assume a leadership role in conducting such investigations. He said the committee encouraged healthcare delivery systems to appoint a chief pharmacy officer, who would attend to issues regarding medication safety and quality.

"As pharmacists, we must raise awareness among our employers of the potential seriousness and frequency of medication errors," Cannon said. "Pharmacy directors or managers must establish policies that allow for the safe and confidential reporting of medication errors, without pharmacists feeling that if the error is reported, they will lose their job."