Adverse drug events in hospitalized cardiac patients.
Approach to Improving Safety
- Discontinuities, Gaps, and Hand-Off Problems
- Side Effects/Adverse Drug Reactions
- Administration Errors
Setting of Care
This study noted two adverse drug events (ADEs) per 100 patient admissions in hospitalized cardiac patients. Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents and anticoagulants were the most common drug classes involved. Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between nurses at shift change. The authors advocate for prevention strategies around medication administration and nursing shift changes to reduce the potential for errors.