Topping that list: All prescriptions should be written electronically by 2010, the Institute of Medicine of the National Academy of Sciences said. At least a quarter of all medication-related injuries are preventable, the institute concluded in the report it released Thursday.
Perhaps the most stunning finding of the report was that, on average, a hospitalized patient is subject to at least one medication error per day — despite intense efforts to improve hospital care in the six years since the institute began focusing attention on medical mistakes of all kinds.
The report was discussed on The Early Show Friday by Dr. Albert Wu, a professor of public health and medicine at Johns Hopkins University. To watch the interview,
The new probe couldn't say how many victims of drug errors die. A 1999 estimate put the number of deaths — conservatively — at 7,000 a year. Also unknown is how many of the injuries are serious.
But a preventable drug error can add more than $5,800 to the hospital bill of a single patient. Assuming that hospitals commit 400,000 preventable drug errors each year, that's $3.5 billion — not counting lost productivity and other costs — from hospitals alone, the report concluded.
"The numbers are big. The injuries are big. This is a problem, it's serious and it continues," said report co-author Michael Cohen, president of the Institute for Safe Medication Practices.
Technology alone could prevent some errors today, but there's too little incentive for hospitals and other care providers to invest, added University of Arizona pharmacy dean J. Lyle Bootman, who chaired the IOM probe.
"We're paid whether these errors occur or not," lamented Bootman, who recently experienced the threat firsthand as his son-in-law dodged some drug near-misses while in intensive care in a reputable hospital.
For now, Bootman advises consumers to be aggressive in questioning doctors, nurses and pharmacists about their medications, whether they're watching over a hospitalized loved one or figuring out their own pills at home.
Take the example of Abe Ticknor, reports CBS News correspondent Elizabeth Kaledin. He was 87 going on 65, his daughter Diane likes to say — old but full of life. But then a doctor in his nursing home overdosed him on the blood-thinning drug Coumadin. He died six weeks later.
How to battle drug errors is a particularly vexing issue because of the sheer volume and complexity of today's medications. There are more than 10,000 prescription drugs on the market, and 300,000 over-the-counter products. Many come with vastly different usage and dosing instructions depending on the patient's age, weight and other risk factors, like bad kidneys.
Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take a least five. The more you use, the greater your risk of taking two that interact badly, especially if different doctors prescribed different drugs without knowing what you already take.
But that's far from the only cause. Doctors' notoriously bad handwriting too often leaves pharmacists squinting to determine if the order was for 10 milligrams or 10 micrograms. Sound-alike drug names — the hormone Premarin or the antibiotic Primaxin? — can confuse health worker and patient alike.
There also are hospital mix-ups involving where a drug is administered. Consider a rare but horrifying one: Accidentally injecting the cancer drug vincristine into the spinal canal instead of giving it intravenously is almost always fatal, and it's a slow, painful death, said Cohen.
Moreover, the instructions given to consumers on how to take their medicine is woefully inadequate, the report concludes. One study found parents gave their children the wrong dose of over-the-counter fever medicines 47 percent of the time.
Then there was the newly diagnosed asthmatic wondering why his inhaler didn't work. Asked how he used it, the middle-aged man squirted two puffs into the air and tried to breathe the mist. It turns out his original doctor had demonstrated the inhaler without explaining that to work, it had to be sprayed inside the mouth.
Among the report's recommendations:
The Institute of Medicine is a branch of the National Academy of Sciences, an independent organization chartered by Congress to advise the government on scientific matters.