On July 20, 2006, the Institute of Medicine, in response to a request by the Senate Finance Committee, issued a report entitled Preventing Medication Errors. The report reached a dramatic conclusion: that every hospital patient can anticipate one medication error a day -- and this doesn't include errors of omission, such as not giving aspirin to a heart attack patient.
The study results are reported in dollars -- the amount it costs to undo a medication error, either in terms of lengthened hospital stays or work days lost -- and comes to $3.5 billion a year. In a way, the number is disappointing. The military budget and the cost of the Iraqi undeclared war have gotten us used to numbers in the trillions. A few billion no longer arouses concern. The House Transportation Bill had $12.4 billion in earmarks, so that, as problems go, medication errors are far less of a problem than the House of Representatives.
But the report is the fourth in a series by the Institute of Medicine. The first, To Err is Human, issued in 1999, estimated that medical errors cost 98,000 lives a year. The numbers are intimidating, and while the Institute of Medicine has made some valuable recommendations to correcting these problems, some of the recommendations haven't been followed, while in other cases, the recommendations for reducing errors run up against policies that are intended to reduce costs, increase profits or pay back political contributions.
One of the recommendations should have been self-evident: electronic prescribing, which is simply a term for legible prescriptions. Physicians' handwriting is a common enough joke, but it's not funny.
But legibility is an individual trait, not a systemic problem, and the reality is, we're faced with a problem that's built into the system, one that leads to medication errors and that never had to be there. America's healthcare financing system is so confusing that it makes extra demands of professionals, even while demanding higher levels of productivity. Medicare Part D isn't the sole problem, but it's the most obvious example because it's the most recent addition and could easily have been designed differently.
Congress had the option of developing a prescription drug benefit plan maintained by Medicare. All patients would have received the same coverage and the same drugs for the same prices. There would have been one formulary and one set of rules. Medicare could have negotiated with drug manufacturers for the best prices, much as the Veteran's Administration does, while low administrative costs would have held the program costs in check. Because so many patients would be covered, physicians and pharmacists would have learned both the formulary and the system so that everything would operate smoothly.
Instead, Congress, at the behest of an industry that has contributed $18,580,144 in campaign funds in 2006 (66% to Republicans), developed a plan that divided the patients among hundreds of insurers, each with their own formulary, prices, rules and business hours. Often, a physician writing a prescription and a pharmacist filling the prescription have no idea whether the drug is covered until the claim is rejected. In the best case, this can be resolved by a telephone call from pharmacist to physician, but often it turns into a series of calls among pharmacist, physician and insurer, complete with repeated assurances that "your call is very important to us, so please stay on the line."
Perhaps health professionals should resist the pressure of a full waiting room or long waiting line of people who expect to be seen at the time they were promised, but by the same logic, major-league baseball players shouldn't be affected by jeers from the bleachers. An inefficient system that demands ever increasing productivity, measured by the number of patients seen and prescriptions filled, puts greater pressure on everybody, increasing the risk of error. The people who gave us self-financing tax cuts and cakewalks in Iraq should understand better than anybody what factors go into making mistakes.
Under pressure, a physician may confuse Flomax with Volmax, or write so hastily that Seroquel is read as Serzone. Under pressure, a pharmacist may grab at a container that looks right, without doing the double and triple check that is, or should be, part of the normal routine. Under pressure, a Republican may even tell the truth. In the words of Donald Rumsfeld, "Stuff happens."
The Institute of Medicine report recognizes a serious problem, and has useful suggestions for reducing risk. There are suggestions for patients (carry a list of your medications at every visit to a physician), for physicians (if you must write a prescription by hand, print neatly, don't scribble), and for hospitals (install computerized drug ordering systems). These suggestions are good. Unfortunately, there are no suggestions for Congress.
Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.
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