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Better At-Home Drug Management Needed to Counter Rising Errors

July 26, 2017

By Ronnie Cohen

(Reuters Health) - The percentage of Americans sickened as a result of medication errors outside of healthcare facilities doubled between 2000 and 2012, according to research highlighting the need for better labeling and dose management.

Medication mistakes outside of hospitals and other healthcare facilities - mostly at home - led to the deaths of 414 people during the 13 years studied, the study found.

More than one-third of the fatal mistakes were related to prescription and over-the-counter painkillers, according to the report online July 10 in the Journal of Clinical Toxicology. Another 30% percent resulted from cardiovascular drugs, primarily beta-blockers.

The errors involved a wide variety of drugs and people of all ages. Most could have been prevented, said lead author Nichole Hodges, a research scientist at the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio.

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“These errors are a significant public health burden with one-third of the cases resulting in hospital admission,” she said in a phone interview.

Most of the errors resulted from patients taking - or caregivers giving - a double dose, patients forgetting that they took the first pill and taking a second, or taking a pill from the wrong bottle, Hodges said.

"Drug manufacturers and pharmacists have a role to play when it comes to reducing medication errors," said co-author Henry Spiller, director of the Central Ohio Poison Center at Nationwide Children's.

"There is room for improvement in product packaging and labeling. Dosing instructions could be made clearer, especially for patients and caregivers with limited literacy or numeracy,” he said in a statement.

Researchers analyzed calls to poison control centers across the nation that resulted in the need for medical treatment. On average, poison control centers get calls about more than 5,200 medication errors a year resulting in serious medical outcomes outside of healthcare facilities.

The number of calls about drug mistakes rose 100 percent, from 1.09 per 100,000 people in 2000 to 2.28 per 100,000 in 2012.

But that doesn’t reflect the true number of out-of-hospital medication errors, Hodges said, because her team counted only mistakes called into poison control centers.

Jody Green, director of research administration at the Rocky Mountain Poison and Drug Center in Denver, said many mistakes could be avoided if consumers read drug labels, and if the labels were easier to read.

“Patients don’t often read the label, even when safety information is present,” she said in a phone interview. “The package inserts that come with prescriptions are often very lengthy. A lot of the time the font is so small that people, especially elderly, can’t read it.”

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One in five of the medication errors in the study involved cardiovascular drugs. Cardiovascular drugs accounted for nearly twice as many mistakes as any other category of drugs, and the number of errors increased over the study period by 177%.

Hodges attributed the increase in cardiovascular drug mistakes at least in part to an increase in the number of people prescribed beta-blockers and other drugs to control heart disease and blood pressure.

Green, who was not involved with the study, believes a number of private and public initiatives likely have slowed the rate of drug errors since the study ended. She is a member of the U.S. Centers for Disease Control and Prevention’s PROTECT Initiative, a task force to advance children’s medication safety.

PROTECT has worked with industry to unify units of measurement on drug containers and instructions, for example, so parents no longer have to try to convert directions given in ounces to drug cups measured in milliliters, or vice-versa, she said.

Nonetheless, more remains to be done, especially to consistently label prescription drugs so consumers know what they’re taking and which other drugs to avoid, she said.

“We need to get away from lengthy pamphlets and think about something that’s more translatable to the general public,” she said.

Hodges advises parents and caregivers to keep a record each time they give a dose of a drug to a child.

“We really recommend that people write it down,” she said. “We recommend keeping a notebook right there with the medication.”

Everyone needs a system to ensure they are taking the right dose of the right medicine at the right time, Hodges said, and added: “Counseling on prescriptions is really important, both by physicians and by pharmacists.”


J Clin Toxicol 2017.

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