Medication Errors Cost State $17.7 Billion and Cause Harm to 150,000 Californians Annually

Throughout 2006 the Panel met at the state Capitol 12 times to hear and discuss testimony from 32 invited speakers who included many widely respected state and national leaders in the fields of pharmacy practice, medicine, medical technology, healthcare regulation, academia and the pharmaceutical industry. During this process, the panel learned that:
• Medication errors are preventable and can occur at any point in the medication use process including prescribing, transcribing, dispensing, using and monitoring.
• Medication errors are often the result of problems associated with incorrect medication use by patients (people prescribed self-administered medications typically take less than half the prescribed doses).
• Low health literacy is a significant contributing factor for many medication errors (even when individuals can correctly read and repeat the instructions, "Take two tablets by mouth twice daily," many cannot accurately demonstrate the actual number of pills to be taken daily).
• Using multiple medications increases a person’s risk for experiencing a medication error, especially when they are prescribed by multiple providers and filled at multiple pharmacies.

Based on the information presented, the Panel developed 12 consensus recommendations on a variety of topics. “The wide range of recommendations from the Medication Errors Panel report provides great direction for systemic changes that are needed in our healthcare delivery system,” said Lynn Rolston, Chief Executive Officer of the California Pharmacists Association. “Simple solutions such as improving communication between the physicians and pharmacists can play a significant role in reducing medication errors and saving lives.”

Such improvements could reduce the proportion of medication errors related to the prescribing process -- particularly those that result from “look-alike/sound-alike” medications such as Quinine and Quinidine or Zyprexa and Zyrtec. While medication names may look or sound alike, their uses can be very different. For instance, Quinine is used to treat malaria, while Quinidine is used to treat heart rhythm disturbances. Zyprexa is used to treat serious mental illness including bipolar disorder and schizophrenia, while Zyrtec is used to treat common allergies.

“Simple errors resulting from medications that look alike or whose names sound alike can prove very dangerous for patients,” said Senator Sheila Kuehl, who participated in today’s press conference. “It’s easy to understand how 150,000 Californians could be injured every year due to medication errors. For instance, think of the potential hazardous outcome of prescribing the allergy medicine Zyrtec to a young child and having that child mistakenly receive Zyprexa, a highly potent antipsychotic. It is a simple mistake yet it can have devastating consequences.”

Recommendations provided by the Panel to address these kinds of problems range from high-tech (e.g. “electronic prescribing”) to low-tech (simply ensuring that the pharmacist and patient are informed of and verify a medication’s intended use). Many other types of errors can also be addressed through improved consumer education about a medication’s purpose, correct use, risks and benefits. The information and consultation that pharmacists provide their patients should play a critical role in this effort. However, the Panel identified many obstacles for pharmacists to provide consultations, including the lack of a payment system to cover the costs incurred while spending time educating consumers.

“Since the U.S. Institute of Medicine first shed light on this issue in 1999, we’ve known about the significant harm caused by errors associated with medical treatments,” Speier said, adding,. “Not enough has been done in California to address this critical issue. The recommendations of the panel will save the lives of thousands of Californians and should be incorporated into legislation without delay.”

The Governor's Secretary of Health and Human Services, Kim Belshe, also agreed with the call for reducing medication errors and said that this is a part of the Governor's health care proposal.

Not only is this good medicine, but given the costs of providing universal health care in California, Senator Kuehl, as Chair of the Senate Health Committee and the author of a bill of her own, will undoubtedly look at this as one of many changes needed to pay for comprehensive bills that emerge from her committee.