Retrospective Analysis of Mortalities Associated With Medication Errors

Jerry Phillips, Sammie Beam, Allen Brinker, Carol Holquist, Peter Honig, Laureen Y. Lee, and Carol Pamer 

Disclosures

Am J Health Syst Pharm. 2001;58(19) 

In This Article

Discussion

The elderly have more ADEs than any other age group does because their exposure to a greater number of medications provides more opportunities for medication errors and drug-drug interactions. In addition, their altered pharmacokinetic values result in an enhanced sensitivity to many drugs.[11] The data presented in this study indicate that elderly patients have the highest rate of death from medication errors. These findings are consistent with previously reported data describing medication use by the elderly, including that polypharmacy can be a contributing risk factor to increased morbidity and mortality in this population.[12] It has been estimated that over one third of elderly patients taking three or more prescription drugs for chronic conditions are rehospitalized within six months of hospital discharge, and 20% of readmissions were caused by drug-related problems.[13] In this review, 55% of patients over 60 years died while taking more than one drug. Twenty-eight percent of hospitalizations of older Americans are a result of noncompliance with drug therapy and adverse reactions.[14] ADEs rank fifth, after congestive heart failure, breast cancer, hypertension, and pneumonia, among the leading causes of preventable threats to the health of older Americans.[15]

Growth in these numbers is expected to occur for two reasons. First, the number and potency of drug products being developed and used are increasing. Second, the elderly population, who consumes the greatest quantity of medications, continues to increase in number.[16]

This review does have several limitations. Because this was a retrospective analysis, we could not interview each reporter to more accurately assess causality of the medication error. Data collected were limited to the AERS database for ease of data extraction and because of time constraints. The FDA's Drug Quality Reporting System database contains another 8784 reports of medication errors resulting in approximately 400 additional deaths. However, some of these reports are duplicated within the AERS database. Another limitation includes underreporting. Thus, the number of deaths within the six-year study period is probably not reflective of a true incidence rate. One study found that only 1% of serious events are reported to FDA.[17] Differential reporting is another possible limitation in that reports of deaths might be disproportionately reported compared with reports of medication errors.

By dissecting the different types of medication errors reported and their root causes, we can direct our efforts toward preventing similar errors by improving health care professionals' communication skills, access to drug information, and the system of drug administration. This could be accomplished by (1) implementing a linked automated system (e.g., computerized direct order entry system, computerized medication administration records, and bar coding), (2) providing easily accessible product information as close to the point of use as possible, and (3) directing immediate attention to the list of drug products in this study and implementing system improvements to minimize future errors. In addition, clinical pharmacists who participate in physician rounds and provide ward-based interventions can dramatically reduce medication errors and costs.[18,19] Numerous researchers and organizations, including NCCMERP, the American Society of Health-System Pharmacists, the Institute for Safe Medication Practices, and the National Patient Safety Foundation, among others, have elucidated additional recommendations for preventing medication errors. FDA is committed to educating the public about the safety of its products. This is an initial effort to provide that accountability as outlined in the February 2000 Quality Interagency Coordination Task Force's report to the President, Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. In addition, FDA's Office of Post-Marketing Drug Risk Assessment (OPDRA) is actively assessing the risks involved when naming, labeling, and packaging its products. OPDRA is reviewing all proprietary names before approving drug products to minimize the possibility of drug products that are named or packaged similarly. In addition, OPDRA is monitoring all reports of medication errors and recommending appropriate interventions, including changing the naming, labeling, or packaging of a drug product.

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