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Journal Article > Study
Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.
Adverse drug events (ADEs) are the most common type of errors in hospitalized patients. This study used data from the Medicare Patient Safety Monitoring System (which conducts detailed chart reviews of hospitalized Medicare patients) to arrive at national estimates for the incidence of ADEs in the Medicare patient population. Errors were common among patients receiving high-risk medications such as warfarin, insulin, and heparin—in fact, nearly 1 in 7 patients receiving heparin experienced an ADE. Medication errors were associated with an increased length of stay, as demonstrated in prior research. A related editorial discusses the MPSMS as an example of a patient-centered approach to detecting harmful errors. A case of an error associated with insulin prescribing is discussed in an AHRQ WebM&M commentary.
Journal Article > Study
Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?
Williams SD, Ashcroft DM. Int J Qual Health Care. 2009;21:316-320.
Assessment of the severity of medication errors reported to the National Reporting and Learning System (the United Kingdom's voluntary incident reporting system) varied widely depending on whether the reporter was a nurse, pharmacy technician, pharmacist, or physician, and whether the reporter personally witnessed the error.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.