Revisiting 'To Err Is Human'

Pharmaceutical CommercePharmaceutical Commerce - July/August 2009

Preventable medical and medication errors should figure more prominently in the current debate on healthcare reform

Over this summer, the leading news headlines have routinely focused on the intense debate in Washington over healthcare reform. Fairly intricate discussions over population demographics, reimbursement rates and the like tend to get boiled down to slogans: “universal healthcare” or “healthcare rationing” and the like. It’s the nature of politically driven debates to reduce a complex topic like healthcare this way; it’s almost as if a sports championship was decided by how well the cheerleaders perform than the athletes on the field. For all its faults, the debate is moving forward, although the final destination cannot yet be identified.

One topic, though, that we wish got bigger play in the debates is the cost and harm of preventable medical errors. This year also happens to be the 10th anniversary of the Institute of Medicine’s To Err is Human report, which put the quality-control problems of the healthcare system in stark terms: some 98,000 lives lost per year due to preventable medical errors (which, it turns out, is likely to be a significant underestimate). Preventable medication errors—which involve pharmaceuticals specifically—take several thousand lives per year.

The costs of these problems was put at $17-29 billion per year then; given inflation (and the inflation in the cost of healthcare specifically), it’s not unreasonable to assume that medical errors cost the American public $50 billion annually today—or, to put it in the 10-year time frames that legislators love to bandy about in Washington, some $500 billion. That’s a sum that should figure prominently in the healthcare reform debate.

The Institute of Medicine followed up the 1999 report with a 2006 study specifically on medication errors. The problems were then, and are now, well known: unclear labeling, too-similar-sounding drug names, and all the problems associated with handwritten prescriptions and instructions. Which shines a light on one of our feature stories this month, “Labels & Package Content” (p. 1). We’re impressed with the range of products and packaging innovations that these suppliers have developed, but our sense is that they are underutilized by the biopharma industry.

The Consumer Reports organization (, noted the 10th anniversary of To Err is Human earlier this year, and came out with an assessment entitled To Err is Human—To Delay is Deadly, noting that very little progress has been made on improving the medical errors situation.

In August, Public Citizen, reviving much of the data published in the IOM reports, estimated that basic patient safety reforms (including reducing medication errors by greater use of computerized physician order entry) could save 85,000 lives and $35 billion annually.

It’s both a blessing and a curse that the biopharma industry is something of a bystander when it comes to how drugs are administered to patients. Healthcare providers have been busy in excluding biopharma industry representatives from their facilities, but then they turn around and blunder—sometimes grotesquely—how drugs are used. Still, the industry can help itself by doing all it can to make its products more error-proof.

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