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U.S. Health Care System Fails to Protect Patients From Deadly Medical Errors
Date:5/20/2009

bing the wrong drug, providing the wrong dose, or using the wrong route to administer drugs to patients. The IOM recommended stronger oversight by the Food and Drug Administration (FDA) to address safety issues connected with drug packaging and labeling, similar name drugs, and post marketing surveillance by doctors and pharmacists. Unfortunately, progress on reducing medication errors has fallen short of the IOM's vision. The FDA reviews new drug names for potential confusion that could lead to mistakes, but few existing names are changed. In addition, a 2008 American Hospital Association survey revealed that only 17 percent of hospitals were using Computerized Physician Order Entry (CPOE) systems, which could help reduce medication errors significantly. The survey found that 45 percent had no plans to implement CPOE systems. Finally, no reliable national medication error system that publicly discloses errors by facility is in place.

Create Accountability Through Transparency: The IOM recommended two national reporting systems to help reduce errors: a mandatory and public reporting system designed to encourage accountability, and a voluntary and confidential reporting system to help health care providers learn from their mistakes. Progress on reporting since 1999 has been made mostly on voluntary, confidential systems that do not create external pressure for change. Twenty four states do not have any medical error reporting requirements in place and most states that require error reporting do not disclose facility-specific information to the public about mistakes, a key incentive for improving patient safety. The federal Patient Safety and Quality Improvement Act of 2005 followed the same pattern of keeping all medical error reports gathered by Patient Safety Organizations confidential. While a network of hospital infection reporting systems is emerging, 24 states do not require infection reporting. Consumers Union recommends
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SOURCE Consumers Union
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