Preventing adverse drug events in hospital practice: an overview

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Introduction

Adverse drug events (ADEs) are a leading cause of medical injury. Depending on the study, there is a wide range of reported frequencies of ADE’s in the hospital setting. Rommers, et al report a range of 2-52 ADE’s per 100 patients in the reports they reviewed for this article. They studied two strategies for preventing ADE’s, one involving the use of a pharmacist on rounds, and the other using CPOE with CDSS (Computerized Physician Order Entry with Clinical Decision Support Systems).

Methods

A search was performed of the literature using Pubmed from the years 1990 to February 2007 using the terms “adverse drug event”, “prevention”, and “hospital”. Additional articles were obtained from the reference section of all reviewed articles. Inclusion criteria were papers that covered ADEs encompassing medication errors and/or adverse drug reactions. Papers involving outpatient events were excluded. Select papers were then reviewed based on ‘exemplary’ current practice, especially in regards to the use of CPOE with CDSS, or pharmacist ward participation as strategies for ADE prevention.

Results

In their review of the literature, the authors were able to come up with some of the most common causes of ADE’s and strategies for prevention of ADE’s. The most common cause of ADE’s was due to deficiencies of knowledge of how the drug should be used, followed by a lack of adequate patient information. The most effective strategies for ADE prevention were: CPOE with CDSS, ward-based clinical pharmacist monitoring, and improved care giver communication. The evidence for the existence of particular patient risk factors for ADE’s was variable. The authors suggested that a multifaceted approach was the best option to prevent ADE’s.

The studies of pharmacist participation on ward rounds showed that the rate of preventable prescribing ADE’s decreased by 66%-78%, depending on the study. Some studies also showed reductions in hospital stay, though mortality rates did not significantly change. It was pointed out that drug administration errors (nurses or others just physically giving the wrong medicine for some reason) were still not prevented by this strategy.

Most of the studies of CPOE with CDSS showed anywhere from a 55% to 86% decrease in various types of medication errors. However some studies showed an unexpected increases in mortality, or facilitation of up to 22 medication error risks. Like with pharmacist participation, administration errors could not be prevented. Clinical event monitoring systems were found to have a true positive rate (meaning suggestion of CDSS accepted by the physician) of 53-92%, but “alert fatigue” was seen in other studies. Linking of laboratory and pharmacy was found to uncover many potential ADE’s, although such connections were often found to be suboptimal or nonexistent.

Conclusion

ADE’s in hospital practice cause significant morbidity and mortality, and can be prevented by a multifaceted approach using several strategies involving both people and technology, in conjunction with improvement in communication.

Comment

This review article was very good at reviewing some of the data that exist regarding reduction in ADE's with both CPOE with CDSS and pharmacist participation on rounds. The pharmacist data did include controlled clinical trial data. However, most of the studies were all very different and a true meta-analysis was not done. This article also reviewed a rather limited number of total papers, perhaps partly because they excluded papers studying outpatient data. So, although their conclusion makes intuitive sense, I think that both methods of ADE reduction require more extensive study and review, with more controlled clinical trial studies.

John Sum