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It’s no secret that the many side effects caused by medicines do not get reported to the Food and Drug Administration, but a new report suggests the magnitude of underreporting is far greater than imagined.

After examining side effects that were conveyed to the regulator for five widely used medicines — two different types of arthritis treatments, an antipsychotic, and a blood thinner — just 1% of an estimated 276,000 serious adverse events had been reported in 2017.

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Meanwhile, the FDA receives approximately 400,000 reports each year from patients, physicians, and drug manufacturers, which implies that as many as 4 million people experienced a serious or fatal injury that was suspected to have been connected with a medication, according to the report from the Institute for Safe Medicines Practices, a nonprofit that acts as a watchdog for prescription drug safety.

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