Editorial
Dying from drugs—at home
The Lancet
Available online 7 August 2008.
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Plenty of places are
hazardous to one's health: smoke-filled rooms, polluted cities, heavily
trafficked roads. But new research adds to what is known about another
potentially dangerous locale—one's own home.
A paper published on July 28 in the Archives of
Internal Medicine reported that fatal medication errors occurring at home
increased substantially from 1983 to 2004. The authors examined all US death
certificates during those years, looking especially for deaths that took place
at home and were classified as resulting from some sort of accident with a
prescription or over-the-counter drug—overdose, wrong drug, or other error.
From a total of nearly 50 million deaths, more than 224 000 were the
result of a fatal medication error. The overall rate of a fatal medication
error, irrespective of location, rose by 360% during the years studied. Fatal
medication errors at home and not combined with other drugs or alcohol rose by
560%. When domestic fatal medication errors were combined with consumption of
alcohol or street drugs, the percentage increase skyrocketed to 3200%.
These increases far
exceeded the death rates from other kinds of accidents, including those
involving traffic, falls, drowning, fires, poisons, and guns, and those
attributed to surgical error, adverse drug effects, and alcohol or street drugs
alone. Furthermore, these fatal medication errors were not confined to a
particular group, but were distributed across a wide range of ages, demographic
classifications, and geographic areas. Interestingly, the increases were
highest for men, whites, and middle-aged people (40–59 years). In fact, more
than half of all fatal medication errors occurred in middle-aged people.
What accounts for these
findings? The use of alcohol and illegal drugs decreased during the period
studied. Prescription drug use has increased, but not nearly as much as fatal
medication errors. Being at home seems to be the major risk factor.
Error in medicine has
been a widely publicised and hotly debated issue, particularly since the
publication in the year 2000 of the US Institute of Medicine's report To Err
is Human: Building a Safer Health System. That report, which stated that as many as 98 000
people die each year from medical error in the USA alone, dealt only with
mishaps that occur in hospitals. As the Archives paper shows, however,
patients are increasingly being taken care of or, more likely, taking care of
themselves at home, not in hospitals. So a high rate of error, transferred from
institutional to domestic settings, although disheartening might not be
especially surprising.
The authors of the Archives
paper say the literature shows “that some patients have difficulty in sharing
the burden of quality control in health care”. But blaming the victims is
hardly the solution to this problem. A more detailed examination of the causes
of fatal medication errors is clearly warranted. We suspect that deeper
analysis will show that the inability or unwillingness of lay people to take
drugs properly at home will not be a sufficient explanation for these dramatic
increases in accidental deaths. It is far more likely that some of those deaths
occurred because patients were both ill and inappropriately at home, and that
several factors combine to increase the risks patients face outside hospital
settings. Insurance companies often pay only for minimum hospital stays; the
high costs of hospital care make early discharge the norm, even when it is not
appropriate for certain patients; home health services can be inadequate or
non-existent; overworked or inattentive doctors might fail to counsel patients
on proper drug use and the dangers of drug–drug or drug–alcohol interaction;
and over-the-counter availability could make drugs seem safer than they are.
If the causes are
disparate and numerous, the good news is that the potential solutions are too.
These statistics make an urgent case for increased awareness and education
about the proper use of drugs and drug interactions, and they highlight the
responsibility of doctors and all health professionals, including pharmacists
in the community, to incorporate this information into routine care of
patients.
The management of hospital stays obviously requires critical analysis; none of the players involved, from governments to policy makers to private insurers, should be exempt from a discussion of their role in what happens to patients outside supervised medical settings. Further research about medication errors and how they can be prevented must now focus on the home front.