Reducing preventable adverse drug events in hospital settings

Abstract

It has been estimated that on average, every patient admitted to a hospital is subject to at least one medication error per day (IOM, 2006). Errors may occur during various stages of the Medication Use System; a system composed of various tasks performed from the point of prescribing medication to the point in which a patient is monitored for adverse effects. Studies have shown that a majority of the errors that occur during the Medication Use System have little if any adverse effect on patients. However, there are classes of medication errors known as Adverse Drug Events (ADE's) which can cause significant harm to a patient. ADE's are not only dangerous but they have been estimated to cost the health care industry and the public in excess of $3.5 billion dollars per year (IOM, 2007). While extensive, current literature that exists on preventable ADE's varies greatly in regards how prevalent the issue is. The lack of a nationwide information system for identifying and defining ADE's only exacerbates the problem. In addition, when significant errors do occur, the repercussions for clinicians and hospitals are far from proportional. Several studies suggest that over one quarter of all medication related injuries are preventable (IOM, 2007).

(cont.) Many industry observers have long touted computerized information systems as the Holy Grail for reducing medication errors. While there is little question that computerized systems can reduce ADE's, hospitals and clinicians frequently ignore other solutions that can offer greater impact in improving the level of care that is being provided. The health care industry has long been touted as fostering a culture that supports at risk behavior and shuns the use of standardized processes. The lack of transparency into the health care industry coupled with an unwillingness to embrace cultural change continues to be one of the largest barriers in reducing the number of preventable ADE's. This paper recommends 4 different solutions that will change the culture of the health care industry, incent hospitals to focus on reducing preventable ADE's, improve the processes already in place for providing patient care and provide clinicians with the most up to date health care information available.