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Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Journal Article > Study
Davis TC, Wolf MS, Bass PF III, et al. Ann Intern Med. 2006;145:887-94.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.