Preventing Medication Errors: Report Brief

Institute of Medicine. Preventing medication errors: report brief. Washington, DC: National Academies Press; 2006.

Almost everyone in the modern world takes medication at one time oranother. According to one estimate, in any given week four out of every fiveU.S. adults will use prescription medicines, over-the-counter drugs, or dietarysupplements of some sort, and nearly one-third of adults will take five or moredifferent medications.

Most of the time these medications are beneficial, or at least they cause noharm, but on occasion they do injure the person taking them. Some of these“adverse drug events [ADEs],” as injuries due to medication are generallycalled, are inevitable—the more powerful a drug is, the more likely it is to haveharmful side effects, for instance—but sometimes the harm is caused by anerror in prescribing or taking the medication, and these damages are notinevitable. They can be prevented.

Against this background, the Centers for Medicare and Medicaid Servicesrequested that the Institute of Medicine study the prevalence of such medica-tion errors and formulate a national agenda for reducing these errors. Theresulting report, Preventing Medication Errors,finds that medication errors aresurprisingly common and costly to the nation, and it outlines a comprehensiveapproach to decreasing the prevalence of these errors. This approach willrequire changes from doctors, nurses, pharmacists, and others in the health careindustry, from the Food and Drug Administration (FDA) and other governmentagencies, from hospitals and other health-care organizations, and from patients.

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