Factors Associated With Reported Preventable Adverse Drug Events

A Retrospective, Case-control Study

Robert D Beckett PharmD BCPS; Amy Heck Sheehan PharmD; Jennifer G Reddan PharmD FASHP

Disclosures

The Annals of Pharmacotherapy. 2012;46(5):634-641. 

In This Article

Abstract and Introduction

Abstract

Background: It has been reported that error occurs at some point during the medication use process in approximately 6% of medication doses administered in the inpatient setting. An estimated 1–10% of medication errors lead to patient harm; however, factors affecting the risk of harm from a medication error are undefined in the literature.
Objective: To identify independent factors affecting the risk of reported preventable adverse drug events (ADEs) (ie, medication errors contributing to patient harm) compared to medication errors that did not contribute to patient harm in a diverse patient population.
Methods: This was a retrospective, case-control study conducted at 3 hospitals within a large health system. Medication error reports from July 1, 2009, through June 30, 2010, were assessed. All reported medication errors determined to have contributed to patient harm were matched 1:1 with a medication error that did not contribute to harm. Data collected through review of the incident report and medical record included patient, provider, medication, and other related factors. Multivariable logistic regression was used to determine the relationship of potential factors to patient harm.
Results: Of 4321 medication errors reported at study sites, 182 (4%) contributed to patient harm. Factors associated with increased independent risk of harm were 30-day readmission, time of day 0300–0659, and Institute for Safe Medication Practices (ISMP) high-alert medications. Factors associated with decreased independent risk of harm were multiple medication errors, occurrence during February or April, dispensing errors, and pharmacist review of medication order.
Conclusions: Health systems should develop programs to promote safe, conscientious use of ISMP high-alert medications, promote pharmacist review, control the use of cabinet overrides, and direct provider attention toward recently admitted patients. Efforts should be made to determine factors associated with risk of harm at local levels.

Introduction

The prevalence of medication errors in inpatient settings is a significant international concern.[1] Because of a general reliance on voluntary incident reporting to quantify medication safety metrics, precisely how many medication errors occur in hospitals is unknown. However, it has been reported that an error has occurred at some point during the medication use process in approximately 6% of medication doses (from a median of 5% in academic hospitals up to 14% in community hospitals).[1–4] Considering the number of medication orders written during an inpatient hospital stay, the potential for error is considerable.

Adverse drug events (ADEs) may be defined as "an injury from a medication (or lack of intended medication)."[5] In the US alone, ADEs are implicated in 7000 deaths, at an estimated cost of $2 billion annually.[1] When an ADE is related to a medication error on the part of any health care professional, it is considered preventable.[6] The percentage of medication errors that have been found to contribute to patient harm has been estimated to be from less than 1% to 10%.[1–4,7–10] The effects of preventable ADEs can range from transient morbidity to mortality.

A number of factors are expected to increase the risk of a medication error becoming an ADE, including the phase of the medication use process (eg, prescribing errors) in which the error occurs.[7,8] Despite the potential adverse outcomes associated with preventable ADEs, independent risk factors for these harmful medication errors, as opposed to those not associated with harm, are fairly undefined in the literature.[1–10] The objective of this study was to review medication error data from a large health system to identify independent factors affecting the risk of reported preventable ADEs (ie, medication errors contributing to patient harm) compared to medication errors that did not contribute to patient harm.

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