Study: More work needed on adverse drug events

Preventable medication errors are still a big cause of sentinel and adverse events and hospitals need to take additional action to prevent serious or life-threatening harm.

A new study funded by the Agency for Healthcare Research and Quality (AHRQ) finds that additional interventions are needed to prevent adverse drug events (ADEs) caused by administration errors in a hospital setting.

The study tracked 14,041 incidents of medication administration and directly observed 1,271 medication administration errors, of which 133 had the potential to cause serious or life-threatening harm. If the sample were applied to hospitals across the country -- where six million doses are administered per year --that would amount to approximately 4,000 preventable adverse drug events caused by medication administration errors annually, according to the study.

Hospitals have long known about the dangers associated with medication management and adverse events resulting from medication errors. The Joint Commission has paid special attention to the consequences that arise from improper or lax medication management practices. Last year’s national patient safety goal -- NPSG03.06.01 (maintain and communicate accurate patient medication information) -- completely revised the way hospitals need to manage patient medication in order to comply with Joint Commission requirements.

Elements of performance include:

• obtaining information on the medications the patient is currently taking when he or she is admitted to the hospital,
• defining the types of medication information to be collected,
• comparing medication information brought in by the patient with the medication prescribed while in the hospital,
• providing the patient and family with written instructions upon discharge, and
• educating the patient on the importance of medication management once they leave the hospital.

Hospitals across the country are re-aligning their medication management teams to reduce errors. As we reported in a recent issue of Inside the Joint Commission, hospitals like UT Southwester Hospitals and Clinics in Dallas and Winchester Medical Center in Virginia are replacing their executive-heavy medication safety teams that focused more on strategy, with front-line committees who can come up with solutions to problems shuch as change of shift pressures and patient education.

Related reading from DecisionHealth: Our Quick Guide to Medication Management, and our newsletter, Inside the Joint Commission.