The Medication Error Problem         Return to the Beginning

When most people enter a hospital or pick up a prescription, it never occurs to them that they might be given the wrong dose of a medication, or a drug not intended for them. Yet numerous studies show that medical mishaps, including medication errors, run rampant in the U.S. health care system.

Consider the heartbreaking story of a Boston Globe health reporter who received a fatal overdose of chemotherapy drugs at the Dana-Farber Cancer Institute - Boston's premier cancer treatment center. In November, 1994, Betsy Lehman, a 39-year-old mother of two, entered Dana-Farber for her third round of chemotherapy for breast cancer.

"She was dealing with horrendous symptoms," her husband, then a scientist at Dana-Farber, told Globe reporters, who wrote an award-winning series on the story. "She was vomiting sheets of tissue. They [Lehman's physicians] said this was the worst they'd ever seen. But the doctors said this was all normal."

On December 3, 1994 - the day Lehman was to be discharged - she left a message on a friend's answering machine sometime after 11:00 in the morning. "She sounded very distraught, tense and agitated," her friend, Hester Hill, told the Globe. "She said, 'I'm calling because I'm feeling very frightened, very upset. I don't know what's wrong, but something's wrong.'"

At 12:15, when a member of Lehman's treatment team came into her room, she was dead. The cause: heart failure due to administration of toxic doses - four times the appropriate amount - of the drug cyclophosphamide for four days in a row. The tragic error wasn't spotted until two months later, when an assistant data manager was doing a routine review of Lehman's hospital stay.

Unfortunately, Lehman's case is just the tip of the iceberg, according to a 2000 report from the Institute of Medicine (IoM), a division of the National Academy of Sciences. The report, which is the first in a series to be produced by the Quality of Health Care in America project, concluded that as many as 98,000 Americans die each year of medical mistakes -- more than the number of lives lost annually to car accidents, breast cancer, or AIDS. Even when using conservative estimates, the number of deaths due to medical errors outranks the number of fatalities attributed to the eighth leading cause of death in the United States. In fact, preventable injuries resulting from health care affect an estimated three percent to four percent of hospital patients.

Medication errors alone kill more than 7,000 people each year, according to the report - more than the 6,000 people lost to workplace injuries annually. A 1997 study found that, on average, two preventable adverse drug events occurred per every 100 admissions. This drove up hospital costs by about $4,700 per admission, or $2.8 million annually for a 700-bed hospital. If these findings are applied to the entire U.S. hospital system, preventable adverse drug events cost some $2 billion annually.

And, that figure is for inpatients alone; it doesn't factor in the costs of medication errors that occur in clinics, nursing homes, and other outpatient settings. Consider that in 1998, U.S. pharmacies filled nearly 2.5 billion prescriptions, costing some $2 billion. A number of studies have documented medication errors resulting from mistakes made in prescribing drugs, errors in the way the medications were dispensed, and unintentional failure of patients to adhere to a prescribed drug regimen.

Research also indicates that children run an especially high risk of suffering a medication error. In one study of more than 100,000 prescriptions, for example, investigators found nearly 500 drug orders with errors, 27 of which were potentially lethal.

According to David Lawrence, MD, chairman and CEO of the Kaiser Foundation Health Plan in Oakland, California, and one of the 19 expert authors of the report, the root cause of the crisis is the fragmented delivery of health care - with doctors, hospitals, and other health-care providers often operating independently. But despite the prevalence of errors and high-profile cases like Lehman's, silence surrounds the issue, according to the IoM.