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Medication/Drug Errors

Last Updated: February 18, 2022
Created By: Dr. Yan Xiao, AHRQ TEP Member

Description
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.
Library Organization
Content Type - This library is organized by the PSNet default organization style.
Primers (2)
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS |

Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty,... Read More

Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.

All Library Content (29)
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Kanaan AO, Donovan JL, Duchin NP, et al. J Am Geriatr Soc. 2013;61:1894-1899.
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.
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.
Field TS, Mazor KM, Briesacher BA, et al. J Am Geriatr Soc. 2007;55:271-276.
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.
Gurwitz JH, Field T, Harrold LR, et al. JAMA. 2003;289:1107-1116.
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.
Field TS, Gilman BH, Subramanian S, et al. Med Care. 2005;43:1171-1176.
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.
Takata GS, Taketomo CK, Waite S, et al. Am J Health Syst Pharm. 2008;65:2036-2044.
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.
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