Medication/Drug Errors

Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) coordinates a nationwide campaign for medication error reporting and prevention which includes a index on types of medication error. They promote recommendations broadly to colleges, schools, and state and national professional organizations and other entities.

This commentary suggests strategies for improving prescribing safety, including linking pharmacy and laboratory data through health information technology.

This cohort study, conducted within a large health management organization (HMO), examined the frequency of adverse drug events (ADEs) that were attributable to errors elderly patients made in handling their medications. Nearly one-quarter of ADEs were caused by patient error, most often due to failure to administer the medication at the proper dose or failure to follow the clinician's instructions on medication use. The classes of medications most frequently associated with errors (hypoglycemics, anticoagulants, and cardiovascular medications) were similar to those found in prior research. A previous commentary discussed the role of preventable and non-preventable patient errors in contributing to adverse clinical outcomes.

This study analyzed more than 1500 adverse drug events and discovered that nearly 28% were preventable. Investigators studied a large population of Medicare enrollees in a single multispecialty group practice capturing events through a number of strategies that included reports from health care providers, review of hospital discharge summaries and emergency department notes, free-text review of electronic clinic notes, and others. The overall rate of adverse drug events approached 50 per 1000 person-years with the most serious events and preventable events occurring at the time of prescribing and monitoring. The authors present a detailed classification of the drug events along with the most common events and medications implicated. While this study focused on an elderly population, a similar study presented their findings from the ambulatory setting in general.

This retrospective cohort study of more than 1200 Medicare enrollees determined that adverse drug events (ADEs) increase the health care costs associated with such events. Building on a previous study in the same patient population, investigators measured costs in the 6 weeks before and immediately after a reported event. Based on the findings, they suggest that the annual costs related to ADEs for 1000 older ambulatory adults approaches $65,000, with more than a third associated with preventable events. The authors advocate for greater quality improvement efforts in this arena as the estimated cost savings make it an attractive and financially advantageous pursuit.

Use of color-coded medications resulted in a reduction in medication errors in simulated pediatric emergency department scenarios.  

This illustrated report provides guidelines for the packaging of pharmaceuticals along with an information design checklist for minimizing medication error.

Hospitalized children may be particularly vulnerable to medication errors given differences in dosing and monitoring of medications. This study, conducted at five California children's hospitals, used several medication error detection methods to characterize the frequency and types of medication errors in this population. Overall, errors requiring pharmacy intervention occurred at a rate comparable to prior studies, but more errors were detected by using a previously validated trigger tool than by standard voluntary incident reporting. The inability of incident reporting to detect medication errors has been documented in prior research.