Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

Daniel J. Cobaugh; Edward P. Krenzelok

Study

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

November 22, 2006

Cobaugh DJ, Krenzelok EP. Am J Health Syst Pharm. 2006;63(22):2228-34.

View more articles from the same authors.

The investigators analyzed medication-related data from a poison control call center and found that 1.6% of the reports of major effects or death were associated with medication errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions.

May 9, 2007

Perceived patient safety culture in a critical care transport program.

July 31, 2013

Rates of medication errors among depressed and burnt out residents: prospective cohort study.

February 20, 2008

A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit.

June 19, 2019

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

February 17, 2010

Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.

August 13, 2008

The recurring problem of retained swabs and instruments.

May 8, 2013

Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin.

April 9, 2008

Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report.

April 3, 2019

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use.

August 16, 2017

Diagnostic stewardship to prevent diagnostic error.

March 15, 2023

Cough and cold medication adverse events after market withdrawal and labeling revision.

December 4, 2013

Reasons provided by prescribers when overriding drug–drug interaction alerts.

November 28, 2007

Clinical decision support in the era of artificial intelligence.

November 21, 2018

Resistance to patient safety initiatives.

December 14, 2005

Medical team training: applying crew resource management in the Veterans Health Administration.

May 30, 2007

From To Err Is Human to Improving Diagnosis in Health Care: the risk management perspective.

March 2, 2016

Labeling solutions and medications in sterile procedural settings.

May 3, 2006

Ambulatory care visits for treating adverse drug effects in the United States, 1995-2001.

July 6, 2005

The effects of resident level of training on the rate of pediatric prescription errors in an academic emergency department.

February 13, 2013

Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.

September 23, 2009

Detecting adverse events in dermatologic surgery.

January 6, 2010

Annals Clinical Decision Making: avoiding cognitive errors in clinical decision making.

May 20, 2020

Assessing patient safety in the United States: challenges and opportunities.

April 3, 2005

Variation in emergency medical services workplace safety culture.

November 10, 2010

Surgical management and outcomes of 165 colonoscopic perforations from a single institution.

August 6, 2008

To expand the evidence base about harms from tests and treatments.

September 15, 2021

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence.

February 26, 2020

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass.

October 22, 2014

Spreading a medication administration intervention organizationwide in six hospitals.

February 15, 2012

Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle.

June 22, 2016

Incorrect surgical procedures within and outside of the operating room.

November 25, 2009

Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

June 7, 2017

The role of practice guidelines and evidence-based medicine in perioperative patient safety.

December 19, 2012

The WHO World Alliance for Patient Safety: a new challenge or an old one neglected?

May 11, 2005

Emergency department visits for adverse events related to dietary supplements.

November 4, 2015

The effect of drug concentration expression on epinephrine dosing errors: a randomized trial.

January 16, 2008

Assessing safety culture: guidelines and recommendations.

August 17, 2005

Is there a 'weekend effect' in major trauma?

February 15, 2017

Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity.

May 20, 2009

End-to-end lung cancer screening with three-dimensional deep learning on low-dose chest computed tomography.

June 5, 2019

Creating safety culture on nursing units: human performance and organizational system factors that make a difference.

January 3, 2007

Diagnostic delays in paediatric stroke.

October 14, 2015

The objective impact of clinical peer review on hospital quality and safety.

February 16, 2011

An assessment of the impact of just culture on quality and safety in US hospitals.

May 9, 2018

An organizational learning framework for patient safety.

April 13, 2016

In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.

November 28, 2018

Delirium in hospitalized older adults.

October 18, 2017

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.

November 27, 2013

Safety issues and concerns for the neurological patient in the emergency department.

July 9, 2008

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

Safety of overlapping inpatient orthopaedic surgery: a multicenter study.

January 16, 2019

Assessment of adverse drug events among patients in a tertiary care medical center.

November 29, 2006

Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA).

April 10, 2024

Unintended doses in radiotherapy—over, under and outside?

April 18, 2018

Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study.

April 10, 2024

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

April 1, 2020

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.

March 5, 2008

Severity and probability of harm of medication errors intercepted by an emergency department pharmacist.

December 14, 2011

Diagnostic error in the pediatric hospital: a narrative review.

February 9, 2022

Best practices for safe handling of products containing concentrated potassium.

August 10, 2005

Digital health technology-specific risks for medical malpractice liability.

December 7, 2022

Physician understanding and ability to communicate harms and benefits of common medical treatments.

September 14, 2016

Registration-associated patient misidentification in an academic medical center: causes and corrections.

January 10, 2007

'So why didn't you think this baby was ill?' Decision-making in acute paediatrics.

April 3, 2019

Time to listen: a review of methods to solicit patient reports of adverse events.

April 14, 2010

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

July 27, 2011

Requirements for the design and implementation of checklists for surgical processes.

August 13, 2008

Association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery.

October 25, 2017

Sleep quality and fatigue among prehospital providers.

April 7, 2010

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.

February 20, 2008

Unplanned return to theater: a quality of care and risk management index?

May 27, 2015

Opportunities to improve informed consent with AHRQ training modules.

June 13, 2018

Barriers to incident notification in a regional prehospital setting.

July 28, 2010

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

December 13, 2006

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment.

December 5, 2018

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

May 6, 2009

Effect of bar-code–assisted medication administration on medication administration errors and accuracy in multiple patient care areas.

July 15, 2009

Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.

September 25, 2013

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

May 5, 2010

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

January 25, 2012

An examination of medical malpractice claims involving physician trainees.

August 19, 2020

Evaluating the impact of auto-calculation settings on opioid prescribing at an academic medical center.

May 8, 2019

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

August 5, 2009

Does Nursing Home Compare reflect patient safety in nursing homes?

November 28, 2018

Seasoned surgeons assessed in a laparoscopic surgical crisis.

May 13, 2009

Variation in medication information for elderly patients during initial interventions by emergency department physicians.

January 16, 2008

Application of patient safety indicators internationally: a pilot study among seven countries.

August 5, 2009

Barcoded medication administration: a last line of defense.

May 21, 2008

Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital system.

May 28, 2008

Disclosing adverse events in clinical practice: the delicate act of being open.

February 2, 2022

National surveillance of emergency department visits for outpatient adverse drug events.

October 18, 2006

Improving incident reporting among physician trainees.

September 28, 2016

Impact of attending physician workload on patient care: a survey of hospitalists.

February 6, 2013

Graduating pediatrics residents' reports on the impact of fatigue over the past decade of duty hour changes.

September 16, 2015

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

May 27, 2015

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

November 25, 2009

Ethics, oversight and quality improvement initiatives.

August 25, 2010

Interventions to improve teamwork and communications among healthcare staff.

March 2, 2011

Related Resources

Implementation of medication reconciliation in outpatient cancer care.

August 9, 2023

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017.

July 5, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Medication discrepancy rates and sources upon nursing home intake: a prospective study.

April 6, 2022

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients.

December 22, 2021

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

December 1, 2021

Deprescribing as a clinical improvement focus.

November 20, 2019

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

May 22, 2019

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

May 8, 2019

Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers.

May 1, 2019

Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity.

November 14, 2018

October 3, 2018

Older adults' awareness of deprescribing: a population-based survey.

February 28, 2018

Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study.

September 13, 2017

High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing?

February 1, 2017

Impact of computerized physician order entry alerts on prescribing in older patients.

March 25, 2015

Higher rates of misdiagnosis in pediatric patients versus adults hospitalized with imported malaria.

November 26, 2014

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens.

November 26, 2014

Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive model.

September 10, 2014

Investigating the long-term consequences of adverse medical events among older adults.

June 11, 2014

Outside case review of surgical pathology for referred patients: the impact on patient care.

April 10, 2013

Scale, nature, preventability and causes of adverse events in hospitalised older patients.

February 27, 2013

Surgeon commitment to trauma care decreases missed injuries.

November 28, 2012

Retained surgical items: a problem yet to be solved.

October 31, 2012

The role of surgeon error in withdrawal of postoperative life support.

September 26, 2012

Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review.

September 19, 2012

Burnout and satisfaction with work-life balance among US physicians relative to the general US population.

September 12, 2012

See More About The Topic

Physicians

Risk Managers

Geriatrics

Side Effects/Adverse Drug Reactions

Specific to High-Risk Drugs

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site