Factors Associated With Preventable Adverse Drug Events
Our study suggests a number of potential factors that could affect the risk for reported preventable ADEs and that several of these independently increase or decrease that risk. The fact that so many of the potential factors did not independently affect the risk for patient harm (Table 6) underscores the multifactorial nature of medication safety and the complexity of medication error. For example, although the univariate analysis suggested a strong impact of certain factors (eg, geriatric age and decreased creatinine clearance) on patient harm, many were not independently noted to increase risk when impact of all factors was considered.
There was no significant difference between groups in terms of patient length of stay at the time of the error or number of medications per patient; this may be because of the academic medical setting and the complexity of most patients. When assessing individual patient risk, we also did not identify a particular population as being at higher (or lower) risk for harm due to medication error with regard to the primary problem or reason for admission. However, the impact of 30-day readmissions on the risk for patient harm, regardless of the primary problem, was striking and underscores the importance of this metric from a clinical and reimbursement standpoint. As organizations expand clinical services provided by the pharmacy department, a targeted focus on patients readmitted following a recent hospital stay may aid in prevention of harmful medication errors. Effort should also be made to minimize the rate of 30-day readmissions.
We found that the timing of the medication error had little impact on harm. The exception to this finding was the increased risk of harm suggested for errors that occurred between 0300 and 0659. While it is theoretically possible that errors occurring during early-morning hours are more harmful, overnight staff may simply be more likely to report harmful errors than nonharmful ones. This finding highlights the criticality of education regarding medication error reporting and the importance of reporting near misses and nonharmful medication errors. When institutions are promoting the practice of medication error reporting, it is vital to target individuals who may not routinely interact with medication safety experts (eg, night shift workers and those in ancillary or outpatient areas). Education regarding medication error reporting should include an overview of the process as well as a description of why this practice is important and the value it brings to the patients and the organization. It is more difficult to explain the findings regarding error reporting in February and April; this study was conducted in a very large health system and it is possible that there were unaccounted trends in error reporting that also affected these results.
The impact of pharmacists on medication safety is highlighted in the provider factor results; the decreased risk of harm found with reported dispensing errors suggests that pharmacists in our system were able to prevent, or identify and correct, significant dispensing errors. Conversely, the dispensing process may benefit from the security of an additional layer of protection (ie, administration) prior to the medication reaching the patient. There was a significant decrease in the risk of patient harm when a pharmacist reviewed a medication order prior to administration. This underscores the importance of pharmacy involvement in the medication use process.
One limitation of our study is that, as an organization, we do not require medication error reporters to disclose their profession and chose not to collect this information. A theoretical bias could limit the applicability of these results if most errors were reported by pharmacists; however, when we reviewed data from the study time period for those who did self-identify, we found that, overall, 55% of medication errors were reported by nurses compared to 39% by pharmacists, 1% by physicians, and 5% by other groups.
Our study also suggests implications pertaining to the use of override functionality of automated dispensing cabinets. Based on the identified impact of pharmacists, override lists should be limited to emergency medications for which a time delay due to pharmacist review would be dangerous to a patient; institutions should routinely assess their override lists, examining both local and national data. Additionally, pharmacy departments should assess their distribution process and technology to ensure that medications are not available for use prior to pharmacist approval of a medication order via other ways (eg, nonsecure medication cabinets).
We found that, contrary to our expectations, patients who experienced more than 1 medication error during the reporting period were less likely to be harmed. The most likely reason for this is that the root cause in the majority of these errors was usually identified as medication reconciliation. At our institution, failures in medication reconciliation usually affected several medications (eg, medication reconciliation was not performed, the wrong patient's list was used), but in a manner that did not translate to patient harm.
We did not identify any particular medication class, route, frequency, or root cause independently affecting risk for harm during medication error; however, as in the case with individual error types, it is likely that there were too few patients in each group to detect meaningful impact in these areas. Despite this fact, emphasis on medication safety programs for insulin, injectable routes of administration (ie, intravenous infusion and injection, subcutaneous injection), and continuously administered medications is warranted. An important related finding was the dramatic increased risk for harm associated with ISMP high-alert medications as a whole; conscientious use of these medications should be emphasized in medication safety programs, organizational metrics, and pharmacy operations processes. Additionally, it is vital that personal responsibility be taken by individual practitioners when ordering, dispensing, and administering these medications to prevent harmful medication errors.
Our results differed somewhat from those of a similar study. Zaal et al. conducted a 2-way case-control study to assess risk factors for harm from medication errors in a general medicine inpatient population. They reviewed 5724 medication errors from 592 patient admissions and found that 102 (1.8%) contributed to patient harm. The authors did not establish any independent risk factors for harm or no harm; however, the study assessed a homogenous population and only 102 errors. In our study, we assessed a wider variety and larger number of patients, which may explain why we were able to establish several independent factors. A greater number and percentage (182; 4%) of our medication errors were considered harmful; this may also reflect our more diverse population of patients.
A second study that had objectives similar to ours was a cross-sectional study performed by Stavroudis et al. This study assessed neonatal intensive care unit medication error reports submitted to MEDMARX; of 6749 reports, 4% were determined to be harmful (ie, preventable ADEs). The authors found a correlation between ISMP high-alert medications, prescribing errors, and equipment/device failure and patient harm; however, the authors did not perform a multivariate analysis or adjust for the impact of confounding factors. We found a similar rate of reported preventable ADEs in our study and our results echo the importance of the ISMP high-alert medication list as a predictor of patient harm.
Finally, a cross-sectional study was performed by Crespin et al. in the setting of long-term care. The objective of this study was to identify factors that contribute to both repeat errors and patient harm. The authors assessed 15,037 medication errors reported to a state agency that represented approximately 26% of the patients cared for at enrolled facilities. Of the medication errors, 123 (0.8%) were determined to contribute to patient harm. Using a multivariate analysis, the authors identified repeat medication errors, errors that occurred between 1500 and 2300, errors in documentation, and temporary staff members as predictors of harm. These factors differed somewhat from our results, highlighting the difference in practice setting and the importance of assessing local trends.
There are a number of limitations to our study that could impact interpretation of the results. Principal among these is that this study aimed to quantify specific factors that affect the risk for harm due to a medication error; while several of these were identified, the multifactorial nature of medication errors should be taken into account when applying these results to practice. For a medication error to harm a patient, multiple steps within the medication use processes must break down. Even though a factor may not have been found to independently affect the risk for harm in this study, it should not be precluded as a factor to be considered by individual practitioners or safety specialists managing medication use systems. Additionally, observational results such as these should not be considered confirmatory. With this in mind, a proactive approach to medication safety using health care failure modes and effects analysis and other tools should be used on a regular basis to minimize the risk of harmful medication errors.
Another limitation is that the data used in the study were collected by a single pharmacist reviewer (RDB); this could increase the risk of bias from a pharmacist perspective. This risk is partially mitigated by the fact that the data were primarily obtained from standard medication error reports prepared by separate individuals with input from relevant medical, nursing, and other staff. Additionally, this individual had training and experience in performing medication error evaluation.
Another important limitation is the breadth of data collected. There are certainly other potential factors affecting the risk of patient harm, such as the training level of individual providers, the familiarity of individual providers with the practice area, time of day as measured by shift, impact of technology, and additional patient-specific information, which were not collected as part of this study.
Finally, as with all single-system studies of this nature, these results may not be generalizable to all hospitals, including other facilities within our own system. Each institution has a responsibility to its patients to carefully evaluate potential failures in the medication use process that apply at a local level, considering the unique nature of its own patient population. While our results may represent potential target points, we strongly suggest, based on these results, that key institutional stakeholders in medication safety evaluate local factors affecting the risk of harm from medication errors. This analysis should focus on the factors assessed in this study, as well as those mentioned as being omitted. The impact of the institution-specific culture of reporting (voluntary, in our case) should also not be underestimated. While our results reflect factors affecting risk for harm associated with reported medication errors, they may not be truly reflective of those errors that remain unreported. Considering that a number of factors appeared to potentially affect risk of harm but were identified too infrequently to assess that risk adequately, we echo previous calls to improve the rate of error reporting by enabling a culture of safety.
In conclusion, preventable ADEs represented 4% of medication errors reported at our institution; approximately 91% of these were NCC MERP category E. Our study suggested a number of potential factors that could affect the risk for a preventable ADE, relative to a medication error that did not cause harm, and suggested that several of these independently affect that risk. Factors associated with increased independent risk of harm were 30-day readmissions, time of day 0300–0659, and ISMP high-alert medications. Factors associated with decreased independent risk of harm were having experienced more than 1 medication error, errors occurring during February or April, dispensing errors, and pharmacist review of the medication order.
Medication safety directors and pharmacy operations managers should develop programs to promote safe, conscientious use of ISMP high-alert medications, promote pharmacist review of orders, and direct attention toward high-risk patients. Efforts should be made to improve the rate of medication error reporting, as it is likely there were too few patients in some groups of factors (ie, medication class, frequency, and route of administration) to assess their impact on the risk of harm, and to identify factors associated with harm at local levels.
Discussion
Our study suggests a number of potential factors that could affect the risk for reported preventable ADEs and that several of these independently increase or decrease that risk. The fact that so many of the potential factors did not independently affect the risk for patient harm (Table 6) underscores the multifactorial nature of medication safety and the complexity of medication error. For example, although the univariate analysis suggested a strong impact of certain factors (eg, geriatric age and decreased creatinine clearance) on patient harm, many were not independently noted to increase risk when impact of all factors was considered.
There was no significant difference between groups in terms of patient length of stay at the time of the error or number of medications per patient; this may be because of the academic medical setting and the complexity of most patients. When assessing individual patient risk, we also did not identify a particular population as being at higher (or lower) risk for harm due to medication error with regard to the primary problem or reason for admission. However, the impact of 30-day readmissions on the risk for patient harm, regardless of the primary problem, was striking and underscores the importance of this metric from a clinical and reimbursement standpoint. As organizations expand clinical services provided by the pharmacy department, a targeted focus on patients readmitted following a recent hospital stay may aid in prevention of harmful medication errors. Effort should also be made to minimize the rate of 30-day readmissions.
We found that the timing of the medication error had little impact on harm. The exception to this finding was the increased risk of harm suggested for errors that occurred between 0300 and 0659. While it is theoretically possible that errors occurring during early-morning hours are more harmful, overnight staff may simply be more likely to report harmful errors than nonharmful ones. This finding highlights the criticality of education regarding medication error reporting and the importance of reporting near misses and nonharmful medication errors. When institutions are promoting the practice of medication error reporting, it is vital to target individuals who may not routinely interact with medication safety experts (eg, night shift workers and those in ancillary or outpatient areas). Education regarding medication error reporting should include an overview of the process as well as a description of why this practice is important and the value it brings to the patients and the organization. It is more difficult to explain the findings regarding error reporting in February and April; this study was conducted in a very large health system and it is possible that there were unaccounted trends in error reporting that also affected these results.
The impact of pharmacists on medication safety is highlighted in the provider factor results; the decreased risk of harm found with reported dispensing errors suggests that pharmacists in our system were able to prevent, or identify and correct, significant dispensing errors. Conversely, the dispensing process may benefit from the security of an additional layer of protection (ie, administration) prior to the medication reaching the patient. There was a significant decrease in the risk of patient harm when a pharmacist reviewed a medication order prior to administration. This underscores the importance of pharmacy involvement in the medication use process.
One limitation of our study is that, as an organization, we do not require medication error reporters to disclose their profession and chose not to collect this information. A theoretical bias could limit the applicability of these results if most errors were reported by pharmacists; however, when we reviewed data from the study time period for those who did self-identify, we found that, overall, 55% of medication errors were reported by nurses compared to 39% by pharmacists, 1% by physicians, and 5% by other groups.
Our study also suggests implications pertaining to the use of override functionality of automated dispensing cabinets. Based on the identified impact of pharmacists, override lists should be limited to emergency medications for which a time delay due to pharmacist review would be dangerous to a patient; institutions should routinely assess their override lists, examining both local and national data. Additionally, pharmacy departments should assess their distribution process and technology to ensure that medications are not available for use prior to pharmacist approval of a medication order via other ways (eg, nonsecure medication cabinets).
We found that, contrary to our expectations, patients who experienced more than 1 medication error during the reporting period were less likely to be harmed. The most likely reason for this is that the root cause in the majority of these errors was usually identified as medication reconciliation. At our institution, failures in medication reconciliation usually affected several medications (eg, medication reconciliation was not performed, the wrong patient's list was used), but in a manner that did not translate to patient harm.
We did not identify any particular medication class, route, frequency, or root cause independently affecting risk for harm during medication error; however, as in the case with individual error types, it is likely that there were too few patients in each group to detect meaningful impact in these areas. Despite this fact, emphasis on medication safety programs for insulin, injectable routes of administration (ie, intravenous infusion and injection, subcutaneous injection), and continuously administered medications is warranted. An important related finding was the dramatic increased risk for harm associated with ISMP high-alert medications as a whole; conscientious use of these medications should be emphasized in medication safety programs, organizational metrics, and pharmacy operations processes. Additionally, it is vital that personal responsibility be taken by individual practitioners when ordering, dispensing, and administering these medications to prevent harmful medication errors.
Our results differed somewhat from those of a similar study. Zaal et al. conducted a 2-way case-control study to assess risk factors for harm from medication errors in a general medicine inpatient population. They reviewed 5724 medication errors from 592 patient admissions and found that 102 (1.8%) contributed to patient harm. The authors did not establish any independent risk factors for harm or no harm; however, the study assessed a homogenous population and only 102 errors. In our study, we assessed a wider variety and larger number of patients, which may explain why we were able to establish several independent factors. A greater number and percentage (182; 4%) of our medication errors were considered harmful; this may also reflect our more diverse population of patients.
A second study that had objectives similar to ours was a cross-sectional study performed by Stavroudis et al. This study assessed neonatal intensive care unit medication error reports submitted to MEDMARX; of 6749 reports, 4% were determined to be harmful (ie, preventable ADEs). The authors found a correlation between ISMP high-alert medications, prescribing errors, and equipment/device failure and patient harm; however, the authors did not perform a multivariate analysis or adjust for the impact of confounding factors. We found a similar rate of reported preventable ADEs in our study and our results echo the importance of the ISMP high-alert medication list as a predictor of patient harm.
Finally, a cross-sectional study was performed by Crespin et al. in the setting of long-term care. The objective of this study was to identify factors that contribute to both repeat errors and patient harm. The authors assessed 15,037 medication errors reported to a state agency that represented approximately 26% of the patients cared for at enrolled facilities. Of the medication errors, 123 (0.8%) were determined to contribute to patient harm. Using a multivariate analysis, the authors identified repeat medication errors, errors that occurred between 1500 and 2300, errors in documentation, and temporary staff members as predictors of harm. These factors differed somewhat from our results, highlighting the difference in practice setting and the importance of assessing local trends.
There are a number of limitations to our study that could impact interpretation of the results. Principal among these is that this study aimed to quantify specific factors that affect the risk for harm due to a medication error; while several of these were identified, the multifactorial nature of medication errors should be taken into account when applying these results to practice. For a medication error to harm a patient, multiple steps within the medication use processes must break down. Even though a factor may not have been found to independently affect the risk for harm in this study, it should not be precluded as a factor to be considered by individual practitioners or safety specialists managing medication use systems. Additionally, observational results such as these should not be considered confirmatory. With this in mind, a proactive approach to medication safety using health care failure modes and effects analysis and other tools should be used on a regular basis to minimize the risk of harmful medication errors.
Another limitation is that the data used in the study were collected by a single pharmacist reviewer (RDB); this could increase the risk of bias from a pharmacist perspective. This risk is partially mitigated by the fact that the data were primarily obtained from standard medication error reports prepared by separate individuals with input from relevant medical, nursing, and other staff. Additionally, this individual had training and experience in performing medication error evaluation.
Another important limitation is the breadth of data collected. There are certainly other potential factors affecting the risk of patient harm, such as the training level of individual providers, the familiarity of individual providers with the practice area, time of day as measured by shift, impact of technology, and additional patient-specific information, which were not collected as part of this study.
Finally, as with all single-system studies of this nature, these results may not be generalizable to all hospitals, including other facilities within our own system. Each institution has a responsibility to its patients to carefully evaluate potential failures in the medication use process that apply at a local level, considering the unique nature of its own patient population. While our results may represent potential target points, we strongly suggest, based on these results, that key institutional stakeholders in medication safety evaluate local factors affecting the risk of harm from medication errors. This analysis should focus on the factors assessed in this study, as well as those mentioned as being omitted. The impact of the institution-specific culture of reporting (voluntary, in our case) should also not be underestimated. While our results reflect factors affecting risk for harm associated with reported medication errors, they may not be truly reflective of those errors that remain unreported. Considering that a number of factors appeared to potentially affect risk of harm but were identified too infrequently to assess that risk adequately, we echo previous calls to improve the rate of error reporting by enabling a culture of safety.
In conclusion, preventable ADEs represented 4% of medication errors reported at our institution; approximately 91% of these were NCC MERP category E. Our study suggested a number of potential factors that could affect the risk for a preventable ADE, relative to a medication error that did not cause harm, and suggested that several of these independently affect that risk. Factors associated with increased independent risk of harm were 30-day readmissions, time of day 0300–0659, and ISMP high-alert medications. Factors associated with decreased independent risk of harm were having experienced more than 1 medication error, errors occurring during February or April, dispensing errors, and pharmacist review of the medication order.
Medication safety directors and pharmacy operations managers should develop programs to promote safe, conscientious use of ISMP high-alert medications, promote pharmacist review of orders, and direct attention toward high-risk patients. Efforts should be made to improve the rate of medication error reporting, as it is likely there were too few patients in some groups of factors (ie, medication class, frequency, and route of administration) to assess their impact on the risk of harm, and to identify factors associated with harm at local levels.
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