.

THE FOLLOWING ARTICLE HAS APPEARED IN THE RECORD January 29, 2003

Know your pharmaceutical
drugs and their effects


Adverse reactions to properly prescribed drugs are not the only reason so many patients suffer serious medical complications including psychiatric disorders and even death. Medication errors by doctors, pharmacists, nurses, and other health care professionals are also a major contributor, especially when it comes to senior citizens and children.

Definition of medication error

A medication error covers any error involved in the process of prescribing, dispensing, monitoring and administrating a drug. They occur both inside and outside hospitals as a result of human mistakes or system flaws. The most common errors have to do with physicians prescribing the wrong medication, the wrong dose or inappropriate combination of medications.

Drug treatment in every hospital setting requires a series of actions that are performed by several individuals, among them - the physician, the hospital pharmacist, and the nurse. As a result, errors are possible at any step of the process beginning from the selection of the medication right up to the moment it is actually dispensed. In 1999, the National Academy of Sciences' Institute of Medicine (IOM) conducted an exhaustive study on hospital patient safety, and found that "drug complications" in the hospital is the leading cause of medical mistakes in America-accounting for nearly 20 percent of all errors. According to the study, medication errors contributed each year to "about" 7,000 deaths in hospitals alone, which is more than all those who die from workplace injuries.

There are also ample opportunities for errors outside of hospital. Each year US retail pharmacies fill over three billion prescriptions while Canada's 23,000 pharmacists dispense upwards of 280 prescriptions. According to the American Society of consultant pharmacists, more than 44,000 deaths result each year from medication-related errors, 7,000 of which are due to mistakes in prescribing or dispensing the wrong drugs. The National Council for Patient Information and Education reported that close to 125,000 deaths occur annually due to adverse reactions to drugs that the physician never should have prescribed.

How often do such tragedies occur in Canada? Unfortunately, we don't have the answer largely because no mechanism exists to track medication errors. However, with our nursing and doctor shortage, packed emergency centers and long waiting lists it would be naive to believe that the problem is any less severe on this side of the border.

Leading to malpractice claims

Prescription errors have frequently led to lawsuits involving patients, families, institutions, and physicians. According to the Physician Insurers Association of America, medication error was the second most frequent cause for litigation. Their finding was based on more than 90 000 malpractice claims over a seven-year period. Were it not for the statutory deadlines, the level of prescription errors that go unreported, the difficulties in obtaining the proper evidence and the complex legal issues, the number of legal claims would be much higher.

Improperly filled prescriptions by pharmacists

Improperly filled prescriptions by pharmacists due to doctors' illegible handwriting has also contributed to medication errors. A doctor's hurried scrawl can easily lead a pharmacist to misread drugs with similar names or abbreviations, misinterpret zeroes and decimal points and ultimately dispense the wrong drug or strength. According to the Institute for Safe Medication Practices, more than two million cases of prescription errors caused by doctors' poor handwriting are reported annually in the United States. A study of pharmacists in Massachusetts found that in a year's time 2.4 million prescriptions (4 per cent of all prescriptions) were improperly filled at the drug store.

Among the various safeguards that have been proposed to reduce the likelihood of such errors is the adoption of an electronic system of prescription ordering and dispensing. Such a system has been recommended both in hospitals as well as in all outpatient facilities, including all physicians' offices. Prescriptions would be entered into a physician's computer and transmitted directly to a pharmacy. So far, the cost factor has been the main obstacle.

Significant risks for those over 65

It should come as no surprise that people over the age of 65, are particularly prone to medication errors and not just because the aging process makes them more sensitive to medication effects. Inasmuch as they consume more than a third of all prescription medications they necessarily face a significantly higher risk of dangerous drug reactions.

Seventy-five percent of elderly people living at home use at least one medication daily while those living in nursing homes consume an average of 6 to 8 medications. Ironically, it is also estimated that almost a quarter of older Americans are sent to hospitals or nursing homes because of problems with medications.

Children are vulnerable

According to the 1999 report of the National Academy of Sciences' Institute of Medicine, children are twice as likely as adults to suffer from a prescription error. The Journal of the American Medical Association considers the odds to be three times higher than adults. In a six-week study at Children's Hospital Boston and Massachusetts General Hospital for Children in 1991, researchers found 616 medication errors out of 10,778 orders written - an error rate of 5.7 percent. As to why children are the most vulnerable to medication errors the medical literature is quite consistent. For one, small and critically ill children are not able to withstand errors as well as older children and adults. Because of their limited weight and wide age range they also require very special dosing considerations. Another reason is because they cannot communicate as well as adults whenever they suffer a side effect.

Various explanations

Numerous reasons have been reported as to why so many medication errors are committed by physicians. The litany of explanations includes everything from the failure to educate themselves about the proper use of modern prescription drugs to the lack of sufficient inquiries regarding their patients' history of drug allergies and other medicines. Another explanation is their failure to monitor their patient's progress so as to make the necessary adjustments. While no one can doubt that the benefits of prescription drugs work wonders there can be no denial that they also contribute to serious medical complications. To make matters worse, time and time again, experts have concluded that the vast majority of fatal and life-threatening medication reactions were preventable. With projections showing that the 65 and older age group will triple over the next 30 years the risks of medication errors are bound to increase unless serious steps are taken. Not surprisingly, the medical literature has not lacked in recommendations on how to deal with the problem. One such recommendation has to do with the compulsory reporting of all prescription mistakes to the proper authorities as well as to the patients and their families. Another one has to do with hospitals retaining consultant pharmacists-drug therapy experts to work with doctors and patients. Their role would be to help ensure that patients don't receive medications they don't need, and that the drugs they do need are used in the proper amount and taken correctly. In the meantime, we must not be afraid to do our own research and to ask our doctors and pharmacists the right questions.