Preventing Medication Errors (2007) / Chapter Skim
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3 Medication Errors: Incidence and Cost
3 Medication Errors: Incidence and Cost
Pages 105-142
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From page 105... ...
As noted in Chapter 1, the committee's charge encompassed developing estimates of the incidence, severity, and costs of medication errors and evaluating alternative approaches to reducing such errors in different settings. To this end, the committee commissioned papers summarizing the salient peer-reviewed literature in the areas of hospital care, nursing home care, ambulatory care, pediatric care, psychiatric care, and use of over-thecounter (OTC)
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From page 106... ...
. INCIDENCE The extent of the research on the incidence of medication errors and adverse drug events (ADEs)
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From page 107... ...
A further confounding factor is that medication error rates are quoted in varying ways -- errors per order/dose/opportunity, errors per 1,000 patient-days, and errors per 1,000 patient admissions. Rates of preventable ADEs are cited in a similar man ner -- preventable ADEs per 1,000 patient-days and per 1,000 patient admissions.
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From page 108... ...
It first addresses the incidence of medication errors in general, and then the incidence of three specific categories of medication errors -- preventable ADEs, underutilization of medications, and overutilization of medications. Incidence of Medication Errors Hospitals As noted, hospital care is the most researched setting for medication error incidence rates, although no study was identified that addressed medi 4There have been many studies of inappropriate prescribing for the elderly in nursing homes, ambulatory care, and home health care, based on such criteria as the Beers criteria (Beers et al., 1991)
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From page 109... ...
used much more comprehensive detection methods -- chart review, including review of written medication orders by a dedicated trained reviewer, in addition to prompted reporting from nurses and pharmacists. This study found a rate of 1,400 prescribing errors per 1,000 patient admissions or 0.3 prescribing errors per patient per day.
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From page 110... ...
for almost 20 years as a quality indicator for nursing homes. It was carried out in Colorado and Georgia in 36 different facilities (12 accredited hospitals, 12 nonaccredited hospitals, and 12 skilled nursing facilities)
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From page 111... ...
, medication administration errors appear to occur in nursing homes at a rate of 620 per 100 doses (Barker et al., 1982, 2002; Baldwin, 1992; Cooper et al., 1994)
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From page 112... ...
Ambulatory Care For the purposes of this study, the committee examined medication error rates in six different settings within the ambulatory care domain: (1) the interface between care settings, for example, from hospital care to outpatient clinic; (2)
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From page 113... ...
. Two studies found high rates of medication errors in ambulatory hemodialysis units (Manley et al., 2003a,b)
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From page 114... ...
An inpatient study covering all types of medications carried out at two urban teaching hospitals reported a rate of medication order errors of 4.2 percent, or 405 prescribing errors per 1,000 pediatric patients (Kaushal et al., 2001)
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From page 115... ...
Psychiatric Care Many studies of medication errors associated with psychotropic medications either were conducted as part of larger general medicalsurgical studies or other ADE-reporting databases, or were restricted to geriatric populations in nonpsychiatric restricted settings, such as nursing homes and ambulatory clinics. The one major study devoted exclusively to medication errors in psychiatric care found a very high rate of errors in a state
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From page 116... ...
One study of 118 caregivers treating their children with a fever reducer revealed that incorrect doses were given 47 percent of the time; another study of 248 caregivers found that 12 percent gave an overdose and 41 percent an underdose; and a third study found that of 200 patients treated for fever by a parent, 51 percent received the wrong dose. Moreover, these studies indicated that a misdose often resulted in a continued fever and an eventual trip to the emergency department.
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From page 117... ...
. · Acetaminophen and ibuprofen can result in kidney damage for those with congestive heart failure and renal impairment.
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From page 118... ...
Preventable Adverse Drug Events ADEs, defined as any injury due to medication (Bates et al., 1995b) , are common in hospitals, nursing homes, and ambulatory care.
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From page 119... ...
. Among the preventable events (preventable ADEs and potential ADEs)
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From page 120... ...
The committee believes the key messages from this series of studies are as follows: · The estimates of about 400,000 preventable ADEs occurring annually in U.S hospitals, derived from the LDS Hospital study (Classen et al., 1997) and the first Brigham and Women's study (Bates et al., 1995b)
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From page 122... ...
. Their findings were as follows: TABLE 3-9 Rates of Preventable ADEs in Nursing Homes Proportion of Preventable ADEs Preventable ADEs per ADE Rate per (No.
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In one of the two nursing home studies by Gurwitz and colleagues (2000) , of the 464 preventable ADEs and potential ADEs identified, 315 occurred in the ordering stage.
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Among these prescribing errors, 46 percent involved wrong drug/wrong therapeutic choice and 41 percent wrong dose. (See Table 3-10 for rates of preventable ADEs in ambulatory care.)
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From page 125... ...
The committee found well-documented evidence of inadequate treatment for acute coronary syndromes, heart failure, chronic coronary disease, atrial fibrillation, bacterial infection prophylaxis, and thrombosis prophylaxis in hospitals. Underutilization of medications in nursing homes and assistedliving facilities relative to national standards is best documented for pain management, congestive heart failure, and use of anticoagulants in stroke prevention and atrial fibrillation, but there is also limited evidence for deficits in use of medications for depression, myocardial infarction prophylaxis, and treatment of osteoporosis.
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From page 126... ...
. Among patients discharged with a diagnosis of acute myocardial infarction, aspirin was prescribed for 5393 percent of ideal candidates (those with no known contraindication)
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From page 127... ...
. Underutilization of Medications in Nursing Homes In a study of residents over age 65 in assisted-living facilities, 62 percent of those with congestive heart failure were not receiving an ACE inhibitor; of those with a history of myocardial infarction, 60.5 percent were not receiving aspirin, and 76 percent were not receiving beta-blockers; of those with a history of stroke, 37.5 percent were not receiving an anticoagulant or antiplatelet product; and of those with osteoporosis, 61 percent were not receiving calcium supplements (Sloane et al., 2004)
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From page 128... ...
For example, using National Ambulatory Medical Care Survey data for 1992, a study found that 51 percent of adult patients diagnosed as having colds, 52 percent of adult patients diagnosed as having upper respiratory tract infections, and 66 percent of adult patients diagnosed as having bronchitis were treated with antibiotics (Gonzales et al., 1997)
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From page 129... ...
Impact of Formularies on Medication Safety In an effort to control the costs of pharmaceuticals, managed care organizations have established formularies -- schedules of prescription drugs that will be paid for by a health insurance plan and dispensed through participating pharmacies. Often patients taking prescription drugs switch from one managed care organization to another, resulting in the need to switch to another formulary.
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From page 130... ...
Costs of ADEs Experienced in Hospitals Only one study was found that estimated the extra hospital costs of a preventable ADE occurring in a hospital. This study, carried out in 1993 within the Adverse Drug Events Prevention Study, found that after adjusting7 for patient comorbidities and case mix, the additional length of stay associated with a preventable ADE was 4.6 days, with an increase in total cost of $5,857 (Bates et al., 1997)
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From page 131... ...
In a study carried out from July 1999 to June 2000, the estimated increased costs (relative to costs incurred in a matched comparison group) associated with ADEs and preventable ADEs among older adults in the ambulatory care setting were $1,310 and $1,983, respectively.
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From page 132... ...
· Ambulatory care -- The best estimate derives from a study (Field et al., 2005) of the costs of ADEs in older adults, which estimated the annual cost of preventable ADEs for all Medicare enrollees aged 65 and older.
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From page 133... ...
The area best understood is the incidence of preventable ADEs in various care settings -- especially in the hospital, but also in nursing homes and in ambulatory care for adults -- where significant problems and their causes have been identified. More research is needed to evaluate the impact of upstream problems on the incidence of errors in the use of medications, as well as the impact of the underutilization of medications.
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From page 134... ...
1995a. Relationship between medication errors and adverse drug events.
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1991. Computerized surveillance of adverse drug events in hospital patients.
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2005. The costs associated with adverse drug events among older adults in the ambulatory setting.
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From page 137... ...
2000. Incidence and preventability of adverse drug events in nursing homes.
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2001. Medication errors and adverse drug events in pediatric inpatients.
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2004. Clarifying adverse drug events: A clinician's guide to terminology, documentation, and reporting.
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From page 140... ...
2001. Practical approach to determining costs and frequency of adverse drug events in a health care network.
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From page 141... ...
2004. Persistent nonmalig nant pain and analgesic prescribing patterns in elderly nursing home residents.
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