Medication Errors Harm Millions of Americans Each Year

Slurred speech. Disorientation. Memory loss. Morris Ganaden thought he was having a stroke.

So did doctors in two emergency rooms, but brain scans and other tests turned up nothing wrong.

Turns out Ganaden, 75, wasn't having a stroke. He was taking the wrong pills.

Despite efforts to prevent medication errors, mix-ups like this are occurring across the country with alarming frequency.

Ganaden, of Independence, was supposed to be taking a common thyroid medication called Synthroid. But a drugstore mistakenly refilled his prescription with Seroquel, a powerful antipsychotic that is used to treat symptoms of schizophrenia and bipolar disorder.

Synthroid tablets are yellow and round. So are the larger Seroquel tablets. Ganaden didn't detect the difference before he had popped the pills.

"If it's in the bottle, you don't pay too much attention to what it is," said Ganaden, a retired engineer. "If it was oblong, I probably would have noticed, but it was round and yellow."

Medication errors -- wrong drug, incorrect dose or improper use -- harm at least 1.5 million people every year, according to the Institute of Medicine. Confusion caused by drugs with similar names accounts for up to 25 percent of the reported errors.

Heartburn drug Zantac gets mixed up with antihistamine Zyrtec. Prostate drug Flomax gets confused with asthma drug Volmax.

Premature infants with intravenous lines have received insulin instead of the blood thinner heparin. Patients with epilepsy have received the AIDS drug Keletra, instead of the anti-seizure drug Keppra. Cancer patients have gotten the wrong chemotherapy when Taxotere and Taxol were confused.

"Unfortunately, these kinds of errors are commonplace," said Jack Fincham, a professor at the University of Missouri-Kansas City's School of Pharmacy. "It's the sheer number of drugs -- the tablets, the capsules -- that look and sound alike. There's lots of room for errors."

Health care organizations and federal regulators are working to prevent these kinds of mistakes, but the job is daunting.

In a 2008 report, U.S. Pharmacopeia, the organization that sets standards for drugs, found 1,470 drugs implicated in medication errors, some lethal, caused by brand names or generic names that sounded or looked alike.

Together, these drugs created more than 3,000 mixed-up pairs, nearly twice the number the organization counted in 2004.

"There has been a lot of attention paid to drug name mix-ups," said Michael Cohen, a pharmacist and the president of the nonprofit Institute for Safe Medication Practices. "But we probably haven't made a lot of progress on the possibility that a patient gets the wrong prescription."