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Switching to computerized entry of drug prescriptions has been shown to decrease serious medication errors by more than 50 percent. But less than 15 percent of U.S. hospitals use the technology. With the computer hardware and software costing $1 million to $3 million at a time when hospitals are under tight budget constraints, money is a major barrier. What's more, implementing computerized order entry requires a major investment in time to train the staff to use it.

Drug errors can be prevented using lower-tech, less costly system changes, however. One is to bring pharmacists onto the hospital floors. In a study conducted at Massachusetts General Hospital, researchers found that adding a pharmacist to a team of doctors making rounds in an intensive care unit cut medication problems resulting from prescribing errors by 66 percent.

Another staffing strategy is to employ dedicated medication personnel, such as specially trained nurses hired solely to administer drugs. In the current health-care climate, nurses are taking care of more patients and sicker patients than they once did. Add 10- and 12-hour shifts to the mix, and the risk of making a mistake rises.

Hospitals can also train staff to work in teams in high-pressure areas such as intensive care units. People make fewer mistakes when they work in teams.

An even quicker fix is to remove concentrated forms of potentially lethal drugs from patient care areas, eliminating the possibility of someone grabbing a concentrated drug by mistake or not diluting it properly.  Manufacturers can also help by placing different medications and different concentrations of drugs in distinct packaging, such as color-coded bottles, and by not giving drugs similar names.

A prime example of name confusion occurred in 1999, when Searle rolled out an arthritis painkiller named Celebrex. As soon as the Institute for Safe Medication Practices (ISMP -- a non-profit group dedicated to thwarting medication mishaps) heard about the drug, they suspected it would easily confused with two other drugs with similar names: Celexa, an antidepressant, and Cerebyx, an antiseizure medication. The ISMP began issuing warnings about the potential problem in journals and in its newsletter in the fall of 1998.

Unfortunately, within weeks of Celebrex's market roll-out in February, 1999, more than 40 reports of errors in writing and filling prescriptions for the drug, resulting from sound-alike/look-alike confusion, had surfaced. Given that at the time physicians had already written some four million prescriptions for Celebrex - one of the fastest-selling drugs ever launched in the United States - experts believe those reports were just the tip of the iceberg. The Celebrex case clearly illustrates the potential problems posed when drugs are given names similar to other medications.

In addition, standardizing the functions of all the medical equipment used in a facility would reduce errors due to unfamiliarity with different machines or poor design, according to Hedy Cohen, vice president of nursing at the Institute for Safe Medication Practices. When a machine is poorly designed, or health-care providers aren't familiar with the design, it's a prescription for disaster.

In 1977, when Cohen was a novice nurse working in an intensive care unit, she pushed the "hold" button on a machine that pumps drugs intravenously at a prescribed rate. She thought when she pushed the button, she stopped the flow of the medication, so she didn't put a clamp on the tube through which it flowed.

Pushing the button simply shut off the machine's pumping action, however. It didn't stop flow of the drug. As a result, the medication, which was designed to raise blood pressure, surged into her patient's body. Within seconds, his blood pressure soared. Because she could see his blood pressure on a monitor, she was able to clamp the tubing. If the drug had continued to flow, the patient probably would have had a stroke within moments.

No one had instructed Cohen on how the machine worked, and she later found out that her error was common. Yet today, more than two decades after the incident, an estimated 25 percent of the IV pumps used in the United States are still that same free-flow type known to cause confusion.

Granted, using system changes to reduce errors doesn't mean forsaking individual accountability. Health-care providers who repeatedly put patients at risk out of negligence or incompetence should still be held responsible for their actions. Nevertheless, to protect patients, medical facilities need to spend time on 10 parts changing the system and one part going after 'bad' guys, according to Dr. Brent James.