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Appendix C: Literature Summary
Pages 215-253

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From page 215...
... c Literature Summary This Appendix summarizes the literature described in Chapter 2. The references cited are at the end of Chapter 2.
From page 216...
... Bhasale et al., 1998 Analysing potential harm in Australian general practice A non-random sample of 324 general practitioners reporting incidents between October 1993 and June 1995. General practitioner-reported free-text descriptions of incidents and answered fixed-response questions.
From page 217...
... Negligence was defined as Death occurred in 6.6% "care that fell below the + 1.2 of adverse events and standard expected of 8.8% + 2.5 of negligent physicians in their adverse events. The leading community." cause of nonoperative adverse events were adverse drug events (19.3% of all adverse events; 35.1% were negligent)
From page 218...
... . McGuire et al., 1992 Measuring and managing quality of surgery 70% of at found to 24% On 6% pots 44,603 consecutive major operations performed at a large medical center from 1977 to 1990.
From page 219...
... , The most common types of found to be preventable, AE is defined as "an preventable errors were 24% unpreventable, and unintended injury that technical errors (44%) , 6% potentially preventable.
From page 220...
... 17 (61°/ died. All conside iatroger been pro Leape et al., 1991 30,195 randomly selected Hospital records.1,133 ads The nature of adverse events records in 51 hospitals in occurre in hospitalized patients New York state (1984~.
From page 221...
... clinical signs and symptoms (28%~. 1,133 adverse events (AEs)
From page 222...
... iatroge the pati' iatroger threater conside in anoth was bel to the d 47 interviews regarding preventable mishaps between September 1975 and April 1977 including staff and resident anesthesiologists from a large urban teaching hospital. Interviewees selected at random from a list of departmental members.
From page 223...
... Critical incident a mishap that "was clearly an occurrence that could have led (if not discovered or corrected in time) or did lead to an undesirable outcome, ranging from increased length of hospital stay to death or permanent disability." 82% of the preventable incidents reported involved human error end 14% involved equipment error.
From page 224...
... anesthesia and surgery based on a study of 599,548 anesthesias in ten institutions Medication-related studies Knox, 1999 Prescription errors tied to lack of advice Globe article Leape, 1999 Pharmacist participation on physician rounds and adverse drug events in the intensive care unit 7,977 of who rec died. Gr anesthe occurre (7.6%)
From page 225...
... , adverse drug events (ADEs) ADE is defined as "an injury due to ordering decreased resulting from the by 66% from 10.4 per administration of a drug." 1,000 patient days before the intervention to 3.5 per 1,000 patient days after the intervention.
From page 226...
... estimate hospital experler and 10E making fourth a causes Wilson et al., 1998 Medication errors in paediatric practice Andrews et al., 1997 An alternative strategy for studying adverse drug events 682 children admitted to a Congenital Heart Disease Center at a teaching hospital in the United Kingdom. 1,047 patients admitted to 3 units at a large, tertiary care, urban teaching hospital affiliated with a university medical school.
From page 227...
... , and drug abuse. Also, this does not include adverse events due to errors in drug administration or noncompliance (taking more or less of a drug than the prescribed amount)
From page 228...
... . Cullen et al., 1997 Preventable adverse drug events in hospitalized patients Prospective cohort study of 4,031 adult admissions to a stratified, random sample of 11 medical and surgical units (including 2 medical and 3 surgical ICUs and 4 medical and 2 surgical general care units)
From page 229...
... "noxious and unintended and occurs at doses used in humans for prophylaxis, diagnosis, therapy, or modification of physiologic functions." The rate of preventable ADE "an injury resulting adverse drug events (ADEs) from medical intervention and potential ADEs in ICUs related to a drug." was 19 events per 1,000 Potential adverse drug event patient days.
From page 230...
... 2,1 03 ern potentia were de overall ~ 3.99 err medica Schneitman-Mclntire Records of 62,216 patients Patient records and pharmacist 1,074 or et al., 1996 who visited the emergency interviews with patients. emerge Medication misadventures department of a California were du resulting in emergency HMO between August misadvc department visits at an 1992 and August 1993 misadd HMO medical center .
From page 231...
... The most common group factors associated with errors were those related to knowledge and the application of knowledge regarding drug therapy (30%~; knowledge and use of knowledge regarding patient factors that affect drug therapy (29.2%~; use of calculations, decimal points, or unit and rate expression factors (17.5%~; and nomenclature factors, such as incorrect drug name, dosage form, or abbreviation (13.4%~. Continued
From page 232...
... 2 adverse drug events care hospital. independent reviewers classified the incidents.
From page 233...
... potential for injury was Physician computer order present." entry could have prevented 86% of potential ADEs, 84% of non-missing dose medication errors, and 60% of preventable ADEs. 247 adverse drug events (ADEs)
From page 234...
... were se threater Leape et al., 1995 All nonobstetric adult Reports from each unit 334 error Systems analysis of admissions to11 medical solicited dailybytrained es the c adverse drug events and surgical units in 2 nurse investigators and prevent. tertiary care hospitals in the peer interviews.
From page 235...
... were serious or life threatening. nit 334 errors were detected Potential ADEs "errors 16 major system failures were ained as the causes of 264 that have the capacity to identified as the causes of ; and preventable adverse drug cause injury, but fail to do the errors, of which the events (ADEs)
From page 236...
... r drug reactions (ADRs) and Intemational hospital resulting from a patient's PharmaccuticalAbstracts hospital noncompliance or as databases settings unintentionally inappropriate 37 articl drug use.
From page 237...
... the drug." Problem order "an incident in which a drug-related error was made, but was judged not to have the potential for injury." ADR "any unintended or undesired consequence of drug therapy." Noncompliance "any deviation from the regimen written (and intended) by the prescriber." 11 reports indicated that noncompliance induced 22.7% of ADR hospitalizations.
From page 238...
... . Injuries in death Classen et al., 1991 36,653 hospitalized patients Integrated hospital information 731 verif Computerized surveillance in the LDS Hospital, Salt system and pharmacist events of adverse drug events Lake City between May 1, review of medical records.
From page 239...
... Although 70.5% gave rise to disabilities lasting less than 6 months, 2.6% of the adverse events caused permanently disabling injuries and 13.6% resulted in death. 731 verified adverse drug events (ADEs)
From page 240...
... for adve teaching hospital. The eve 3.13 err orders \1 of signil 1.81 pet Sullivan et al., 1990 Noncompliance with medication regimens and subsequent hospitalizations 7 studies and 2,942 admissions with comparable methodologies and evaluation regarding the extent and direct cost of hospital admissions related to drug therapy noncompliance.
From page 241...
... . Of these 15 noncompliance, recent dose admissions, 5 cases were reduction/discontinuation, judged to have been "definitely avoidable." interaction or inadequate monitoring." 905 prescribing errors were Medication errorsdetected and averted, of "medication orders for the which 57.7% had a potential wrong drug, inappropriate for adverse consequences.
From page 242...
... medication errors about the study monitors. Universi which the physician had 1,012 er been contacted.
From page 243...
... The frequency of iatrogenic injuryofanysortduetoa medication error was 3.1%, or 1 for each 33 intensive care admissions. 66 errors resulted in injury, 33 were potentially serious, 32 caused mild injuries, and 1 patient suffered acute aminophylline poisoning.
From page 244...
... Rates of ADRs r 43.5%. studies rates be Folli et al., 1987 101,022 medication orders Copies of errant chart ordersA combin Medication error prevention prescribed in two children's reviewed by a member oferrant n by clinical pharmacists teaching hospitals (Miller the pediatric faculty or were idr in two children's Children's Hospital of attending physician and by instituti hospitals Memorial Medical Center two pediatric clinical SUMC ~ tMMC]
From page 245...
... Involving therapeutics committees pharmacists in the reviewing of each hospital." of drug orders reduced the potential harm resulting from errant medication orders significantly. The mean test score for nurses was 75.6%.
From page 246...
... Jick, 1974 19,000 inpatients admitted Boston Collaborative Drug 30% of he Drugs: remarkably to medicalwards. Surveillance Program patients nontoxic adverse (ADR)
From page 247...
... ~ Drug am Adverse drug reactions (ADRs) occur in approximately 30% of hospitalized patients and after about 5% of drug exposures.
From page 248...
... Medical records of 14,732 randomly selected 1992 discharges from 28 hospitals in Utah and Colorado Two-stage chart review by trained nurses and board-certified family practitioners and internists. An esters lethal at reaction of 60,0E to a higl .
From page 249...
... The total hospital stay or disability costs were $661,889,000 at time of discharge." for adverse events and $308,382,000 for preventable adverse events. Health care costs were $348,081,000 for all adverse events and $159,245,000 for preventable adverse events.
From page 250...
... Survey of an expert panel consisting of consultant pharmacists and physicians with practice experience in nursing facilities and .
From page 251...
... The estimated annual costs for a 700-bed teaching hospital attributable to all ADEs are $5.6 million and to preventable ADEs are $2.8 million. The national hospital costs of ADEs was estimated at $4 billion; preventable ADEs alone would cost $2 billion.
From page 252...
... or medication error. 1 ,91 1 A errors rig volunta' in 1994 annual $1.5 mi Bloom, 1988 Retrospective analysis of all Medicaid Management Cost of treating arthritis and direct costs related to the Information System of NSAID-related care of 527 Medicaid Washington, D.C.
From page 253...
... In 1983, an estimated $3.9 million was spent on treating preventable gastrointestinal adverse drug reactions to NSAIDs. Gastrointestinal adverse drug reaction "any claim for payment accompanied by a diagnosis of peptic ulcer, gastritis/duodenitis, other disorders of the stomach or duodenum, gastrointestinal symptoms, or a pharmacy claim for an H2-recepter antagonist, sucralfate or antacid, which occurred during the arthritis treatment study period.


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