Such adverse drug reactions are a problem that plagues all of America's hospitals.  They are a threat to patient health that experts say has long been ignored, overlooked or hidden from view, although they are a major source of hospital based errors that cause patient deaths.

At St. Francis Hospital in Peoria, (Illinois*) for example, computers now churn out 350 to 400 alerts every day warning of possible drug reactions from the nearly 4,000 prescriptions written daily. Many are minor, like a slight rash. But where they could cause serious harm or even death, orders are changed, doses altered and potentially dangerous drugs replaced by safer ones.

Catching and dealing with these preventable complications before they hurt patients has enabled the 750-bed hospital to reduce its rate of adverse drug reactions dramatically, from 4 per 1,000 doses of medications five years ago to 1.4 today. The Illinois Hospital Association has launched a pilot program to test the St. Francis system at (Twenty Six*)26 hospitals, including several in the Chicago area.

But St. Francis' safety net is not typical. Drug errors are seldom acknowledged--and when they are uncovered the fault is usually laid at the feet of a convenient scapegoat.

Only about (five *)5 percent of all drug reactions that occur in hospitals are ever reported,  Dr. David W. Bates of Boston's Brigham and Women's Hospital and Harvard Medical School, found in a study.

"Most hospitals rely on spontaneous reporting to find these reactions, and people just don't report most of them," he said. "So most hospitals have a problem that is (twenty*) 20 times as big as they routinely know about."

In Illinois, for example, (two*) 2 percent to (seven*) 7 percent of hospital patients are believed to be harmed as a result of drug side effects,  a rate that officials agree puts too many patients at unnecessary risk.

Now, the realization seems to be growing that fundamental changes must be made to improve patient drug safety.

One of the biggest changes is acknowledging that humans make mistakes and that medicine has become so complicated that errors are inevitable under the current system of paper medical record keeping.

"We're talking about 10,000 drugs,"  said Dr. Robert Wachter, director of patient safety at the University of California Medical Center in San Francisco. "Knowing all the potential interactions between drugs is something that is now beyond the capacity of a Rhodes Scholar to remember."

"The old model of thinking was blame and shame," said Dr. John Whittington, patient safety officer for the OSF HealthCare system, which includes St. Francis and five other hospitals. "You made a mistake, you're a bad person.

"The new model is, `No, the only way we're going to improve is by revealing our mistakes,'" he said. "That's what the airlines did and that's what enabled them to make big progress in improving safety."

* New developments

"It was a matter of collective inattention," he said. "Medical errors are a generic problem, and we've all been silent about it in part because of malpractice, the media and shame."

The code of silence was first broken five years ago when the Institute of Medicine, an arm of the National Academy of Sciences, released a blistering report, "To Err is Human: Building a Safer Health System."

The institute estimated that 44,000 to 98,000 people die annually in U.S. hospitals from medical errors. The single biggest source of these errors, it said, is adverse drug events.

"We're trying to move more towards what we call the just culture," Whittington said. "In the just culture we're saying, `Look, we're human beings and we make mistakes. Let's report our mistakes. Let's figure out how we can correct these mistakes and move on."

Not all adverse drug reactions are the result of human error. One out of 10 hospital patients on average will suffer an adverse drug reaction, but only about one third of them are preventable, said Harvard's Bates.

Drug errors are considered preventable when it is known that two drugs become dangerous when mixed; that a patient has a known allergy to a medicine; when age or illness turns a routine drug dose into an overdose; or when the wrong drug is given.

Some drug reactions are impossible to know before a drug is given for the first time. Neither a doctor nor a patient, for example, knows if a drug will cause a reaction until that medication is administered.

Boston's Brigham Hospital was one of the first in the country to implement a computerized system enabling doctors to order medications, tests and other medical procedures directly online.

The error checking system started in 1993 and so far has reduced the number of serious medication mistakes by 55 percent, saving the hospital $5 million to $10 million a year, Bates said.

Whittington said the OSF HealthCare system began a major effort to deal with the drug reaction problem in 2001, realizing then that to reduce human error, the system of dispensing drugs would have to be made as fail safe as possible.

That meant finding out all the drugs a patient was taking at home and double checking new drugs prescribed in the hospital for potential side effects, a task now routinely done by computers in the pharmacy department. The safety system focuses on high risk medications. The big three error prone drugs are insulin, which can lower or raise blood sugar to dangerous levels; pain-relieving narcotics, which at high doses can cause respiratory arrest; and anticoagulants, which can cause excessive bleeding.

Program expands

The purpose is to "identify weaknesses and adopt the best practices to address those weak points," said Cathy Grossi, the IHA's director of health policy and regulation.

A second program, also started in January, is designed to cast an even broader net for drug safety, said Bruce Lambert of the University of Illinois at Chicago's College of Pharmacy.

The two-year pilot project, funded by a $100,000 grant from the Michael Reese Health Trust, plans to use the IHA's medication reconciliation program as its core, and then expand around it to reach patients' family doctors as well as the drugstores where they fill prescriptions. It will involve UIC and two other hospitals.

A major stumbling block to the rapid deployment of a drug safety system is the lack of electronic medical record systems in hospitals. Many Illinois hospitals, especially the teaching institutions, are computerizing the way they handle prescriptions, lab tests, diagnoses and patient histories, but it is an expensive process and takes time.

Whittington cautioned that setting up a computerized medical record system without first developing a program that ensures safety can lead to a new set of complications and problems.

"A lot of times people think of electronics as a kind of black box where magic will happen," he said. "`We'll just let the computer do that.' It doesn't work like that. What you put in is what you get out, and it's the same in health care."

For Jerry Storm, St. Francis Hospital's director of pharmacy, the computerized medical records system has opened a new world of drug safety.

Pharmacists now watch for adverse drug alerts that appear as pop up warnings of drug reaction, allergy, overdose or wrong drug.

Eighty percent of the time physicians accept recommendations from pharmacists and change their orders.

"It's been a cultural change," Storm said. "The doctors are much more receptive when they get a phone call from us now than what they were 5 years ago. There's a lot more heightened awareness regarding medication errors."