Deaths from Fatal Med Errors at Home Skyrocket-August 2008

A comprehensive analysis found that deaths from misuse of medications at home increased from 1132 deaths in 1983 to 12,426 in 2004. The findings, based on nearly 50 million US death certificates, were published in the July 28, 2008, issue of the Archives of Internal Medicine.

The researchers defined fatal medication errors to include incidents in which patients died from overdoses, mixing medications with alcohol and/or street drugs, and taking the wrong medication—prescription or OTC. For the study, the researchers divided the medication-related deaths into 4 categories:

• Deaths resulting from misuse of prescription medications while at home usually, when an individual combined the medicine with alcohol and/or street drugs. The number of fatalities rose 3196% during the >2-decade period.
• Deaths resulting from medication mistakes at home without alcohol or street drugs involved increased 564%
• Deaths from nonhome medication errors involving alcohol and/or street drugs rose 555%
• Deaths from medication errors in a health care or other setting rose 5%

Lead researcher David Phillips, PhD, a sociologist at the University of California San Diego, said that health care professionals must aggressively warn patients about the dangers of mixing alcohol or street drugs. He said that with health care shifting from inpatient to outpatient settings, the result is less supervision of medication use.

“The amount of medical supervision is going down and the amount of responsibility put on the patient’s shoulders is going up,” he said.

Pharmacists also weighed in on the findings. The increase “calls for mandatory, scripted patient education when patients obtain certain prescription drugs,” said Michael Cohen, RPh, president of the Institute for Safe Medication Practices, in the July 29 San Diego Union-Tribune.

Educating the public is not easy, however. Pharmacist John Cronin, former legal counsel for the California Pharmacists Association, told the newspaper, “You can tell people. You can put it in writing on the label. But you cannot make them read it or listen. The health care system today does not allow for physicians, nurses, or pharmacists to sit down with people for the period of time necessary to drive this home.”

While California requires patient education before clinicians dispense medications, it is not always a reality, according to Cohen. “A pharmacist could spend an hour educating the patient, working by phone with the doctor, and not receive 1 cent” other than a fee for filling the script.