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The July 2006 IOM Report on Medication Errors
For the second time in less than a decade, a report by the Institute of Medicine (IOM) was released in July. The previous IOM report on the subject, released in 1999 and titled, 'To Err Is Human,' rocked the medical community when it estimated that 44,000-98,000 Americans die each year as a result of medical errors. Similarly, the report released in July documents significant shortcomings in the provision of medical services in this country and startlingly points out that medication errors continue to harm at least 1.5 million people every year. According to the new report, the problem is so serious that, on the average, a hospital patient is subject to at least one medication error per day. The IOM estimates that the additional costs of treating medication-related injuries ' those occurring in hospitals alone ' can conservatively be estimated at $3.5 billion per year. At least one quarter of all such injuries are apparently preventable.
Why Another Study?
It is helpful to consider both the recent as well as long-term history of similar studies to place the IOM Report in proper perspective. Initially, following the 1999 publication of 'To Err is Human,' Congress ordered the IOM to 'carry out a comprehensive study of drug safety and quality issues in order to provide a blueprint for system-wide change.' Congress defined the objective of the study in the Medicare Modernization Act of 2003 (Section 107(c)) to include development of a full understanding of drug safety and quality issues through a comprehensive review of literature, case studies, and analysis. This review was designed to consider the nature and causes of medication errors and their impact on patients, as well as the differences in causation, impact and prevention across multiple dimensions of healthcare delivery (including not only patient populations, but care settings, clinicians, and institutional cultures). Congress also mandated that the IOM develop credible estimates of the incidence, severity, and costs of medication errors, which could be useful in prioritizing resources for national quality and preventive efforts and, beyond that, influence national healthcare policy.
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