Some authorities estimate that medication errors account for almost 7,000 deaths each year in the U.S.; others say that adverse drug reactions (ADRs) account for as many as 106,000 deaths annually in the U.S. From 3% to 28% of all hospital admissions are related to ADRs, and 10% to 20% of ADRs are considered preventable.

The IOM estimates that medical (not just medication) errors cause 44,000 to 98,000 deaths annually in American hospitals and that medication errors account for one out of 131 outpatient deaths and one out of 854 inpatient deaths.
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To put a financial perspective on this problem, the hospital costs of ADRs in the U.S. have been estimated to be as high as $4 billion per year. In total, more than $175 billion is spent annually in the U.S. to treat ADEs, representing $1.33 spent treating ADRs for every $1.00 spent on medications.

In 1980, medical school graduates had to become familiar with the safety profiles of about 60 drugs; by the year 2000, this number had grown to 300 drugs. Potential drug-drug interactions have increased dramatically with the rise in the number of potential drugs administered. Medical schools in the nation now struggle to catch up to ever-growing educational demands, as quoted by one educator:

“The problem that we’re really facing is lack of education. The average medical student receives 27 minutes [of instruction] on opioids in four years of medical school.”

Dr. Raymond Woosley, in a personal conversation (June 19, 2004) stated that only about 20 medical schools had formal courses in clinical pharmacology.

In curriculum committees, there is intense pressure for medical students to spend time in required courses as well as a push for them to spend more time taking elective courses. Jefferson Medical College in Philadelphia offers an elective course called Clinical Pharmacology and Therapeutics, but only 30 to 40 of the 230 senior medical students have chosen to take it. A description of the syllabus can be seen on the Thomas Jefferson University Clinical Pharmacology.

SPECIAL CHALLENGES IN AMBULATORY MEDICINE

ADEs are identified more often in ambulatory medicine than in inpatient practices. The evidence suggests that the rate of ADEs among ambulatory patients may be as high as 27% (compared with 3% to 5%, as cited for inpatient therapy), pos­sibly reflecting the longer rates of exposure or less intensive monitoring for outpatients.

ADRs can be difficult to identify and manage in ambulatory care, but the difficulty does not alter the profound importance of this public health problem. The individual events themselves can be subtle and infrequent, lost amid a sea of frenetic outpatient activity. For example, although ADRs are estimated to be the fourth to sixth leading causes of death in the U.S., NSAIDs are associated with just 5.5 hospital admissions per 10,000 patients treated with these drugs in primary care. Many hospital admissions are not recognized or documented as resulting from an ADR. The challenges in recognizing the problems are exceeded only by their importance in public health.

It is interesting to note that the more severe ADEs are also the most preventable. This may be an unexpected finding, but it is indeed fortunate. In 2003, Gurwitz et al. estimated that more than 25% of 1,900,000 ADEs were potentially avoidable. Furthermore, of 180,000 life-threatening or fatal ADEs per year, more than 50% were considered preventable. These authors concluded that the most severe ADEs were also the most avoidable. UK viagra

One might think that the largest risk is derived from medications that physicians prescribe infrequently and with which they are not thoroughly familiar. However, most ADEs occur with the drugs that are commonly used; consequently, it is these drugs that should be the prime target of improvement programs. This fact is probably statistically driven: the more frequently a drug is used, the more errors will result, even if the percentage of ADEs relative to the number of usages is lower.

In one cohort study of 30,397 Medicare enrollees in a multi-specialty group practice, Gurwitz et al. concluded that “the prescription of a drug for which there was a well-established, clinically important interaction [with warfarin] was a common error.”

Another recent study of 49,658 electronic medical records revealed four patterns of care that resulted in 72% of drug-related morbidity events that could have been averted:

  • prolonged use of NSAIDs in people with known hypertension, congestive heart failure, peptic ulcer disease, or upper gastrointestinal bleeding
  • use of angiotensin-converting enzyme (ACE)-inhibitors with inadequate monitoring of serum creatinine and potassium levels
  • use of a hypnotic-anxiolytic agent with a long half-life
  • failure to provide secondary coronary prophylaxis with beta blockers

These widespread problems result from commonly prescribed medications.

The United States Pharmacopeia (USP) Patient Safety offers a wealth of reviews of medication-related issues. Although the site’s MEDMARX medication-reporting program tracks hospitalized patient information (i.e., inpatient medication errors), it is not surprising that some of the most commonly administered drugs are the ones most often associated with medication errors.
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The five drugs most commonly associated with errors, as described in the USP Drug Safety Review of December 8, 2003, were insulin, albuterol, morphine, potassium chloride, and heparin.