This Second Edition Has Detailed, Useful Information For Doctors And Pharmacists

(Posted by Tom Lamb at DrugInjuryWatch.com)

The August 9, 2007 edition of The New England Journal of Medicine (NEJM) has an insightful book review by John P. Burke, M.D., of LDS Hospital in Salt Lake City, UT, which does a very good job of introducing us to a valuable new book, "Medication Errors", second edition, edited by Michael R. Cohen.

As has been reported previously, the Institute of Medicine (IOM) estimates that at least 1.5 million Americans are sickened, injured, or killed each year by medication errors. 

For this new book "Medication Errors", editor Michael R. Cohen — a pharmacist and the president of the nonprofit Institute for Safe Medication Practices (ISMP), as well as a 2005 recipient of a John D. and Catherine T. MacArthur Foundation "genius grant" — defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."

In more detail, from Dr. John Burke’s book review in the August 9 NEJM:

This definition includes errors at any stage of medication use and not just during the process of drug administration. Cohen believes that the "five rights" of safe medication use (the right patient, right drug, right time, right dose, and right route of administration) place too much focus on individual performance and overlook the systemic problems that underlie the human errors. He emphasizes that "finding out who was involved is less important than learning what went wrong, how, and why."

According to Dr. Burke, both a new IOM book "Preventing Medication Errors", which he also covers in this NEJM book review, and the second edition of "Medication Errors" call for the elimination of handwritten prescriptions.

As regards this last point, in a June 27,2007 HealthDay article, "Prescription Mistakes: Computerized Ordering Cuts Medication Errors", we learned the substantial benefit obtained by this type of change in prescribing methods:

U.S. hospitals that switched from using doctors’ handwritten prescriptions to computerized drug ordering systems had a 66 percent drop in medication errors, say the authors of a review that looked at the results of 12 studies.

The findings are published online in the journal Health Services Research….

Illegible handwriting on prescriptions and transcription mistakes cause as many as 61 percent of medication errors, the experts said….

Currently, only about 9 percent of U.S. hospitals have computerized prescription systems, which can take 12 to 36 months to implement.

Hopefully more doctors and hospitals will move to computerized drug prescription systems in the next few years so as to improve this aspect of drug safety in the U.S. sooner rather than later.