Following up its landmark 1999 report To Err Is Human, the Institute of Medicine issued Preventing Medication Errors: Quality Chasm Series in July. The new report, a comprehensive review of the causes, extent, and costs of adverse drug events (ADEs) in U.S. health care facilities, states that ADEs arising from errors are "surprisingly common and costly to the nation." Other findings include the following:

* At least 1.5 million preventable ADEs occur in the United States each year-and this is considered a conservative estimate.

* The average hospitalized patient can expect to experience more than one medication error each day.

* Each preventable ADE adds about $8,750 to the cost of the hospital stay.

In strong language, the report termed the current state of affairs "not acceptable," and recommended a series of steps to prevent medication errors. These include more cooperation between the drug industry and federal agencies to eliminate similar or misleading drug names, abbreviations, and acronyms. The report also calls for moving toward "a model of health care where there is more of a partnership between the patients and the health care providers."

The entire report is available at http://www.nap.edu.