Medication Mistakes Kill More Than 7,000 Hospitalized Patients Each Year In U.S.
On January 25, 2006 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued an alert urging hospitals to take several steps intended to avoid drug errors that often occur when patients are transferred or discharged.
According to this JCAHO safety alert, in 2005 there were more than 2,000 cases of drug errors or medication mistakes were submitted to a voluntary medication error reporting program for health care providers maintained by U.S. Pharmacopeia. Due to the generally acknowledged "under-reporting" of the medication mistakes, however, it has been estimated that drug errors kill more than 7,000 hospitalized patients nationwide each year.
The JCAHO report stated that most of medication mistakes involving hospitalized patients -- such as getting double doses causing an adverse reaction or incompatible drugs resulting in a drug-drug interaction -- are due to inadequate record-keeping.
According to this 2006 JCAHO safety alert -- entitled "Sentinel Event Alert Issue 35: Using medication reconciliation to prevent errors" -- hospitals can help avoid these types of medication errors by:
- listing medications and proper doses in a "highly visible" place on patient charts;
- communicating that information to doctors, nurses, and patients during transfers; and,
- making sure patients have accurate lists of medication and instructions for use when discharged.
One hopes that all of the 15,000 hospitals and health care organizations which received this January 2006 JCAHO alert about medication errors will take action to implement these simple but very significant steps.
(Posted by: Tom Lamb)