Most Preventable Drug Reactions from Doctors' Errors 

AP 4mar03

[Abstract below]

CHICAGO -- Largely because of doctors' errors, older nonhospitalized Americans suffer about a half million preventable drug side effects each year, ranging from nausea to life-threatening kidney failure, a study suggests.

About 20% of the side effects are caused by patients' mistakes, said the researchers, who studied about 30,000 people on Medicare in New England. But most of the preventable drug reactions result from doctors' errors.

"It's obvious that it's a major issue, a major problem," said Dr. Jerry Gurwitz, the lead researcher and a professor at the University of Massachusetts Medical School.

The findings appear in Wednesday's Journal of the American Medical Association.

Previous studies have found similar results in hospitalized patients, but there is little data on nonhospitalized patients, the researchers said.

With nearly 40 million Americans on Medicare, the government's health program for people over 65, the results suggest that more than 1.9 million drug side effects -- about one-fourth of them preventable -- happen each year in nonhospitalized elderly people.

About 180,000 of the bad reactions are life-threatening or fatal, and more than 40% of these may be preventable, the researchers said.

Citing data showing that more than 90% of adults age 65 and older take at least one drug per week, and about 40% use five or more weekly, they said their figures probably underestimate the problem.

A Journal of the American Medical Association editorial said the study helps "provide a clearer view of the illusion of medication safety."

"Medications still pose a significant risk to patients ... despite decades of research and advances in drug therapy," said editorial author Dr. David Classen of the University of Utah.

Better communication among doctors could help prevent some bad reactions, Dr. Gurwitz said.

Educating patients could also help, said co-author Dr. David Bates of Boston's Brigham and Women's Hospital. "Making sure they understand what they are taking, why they are taking it, and when they should take it remains a key component in preventing adverse drug events in the outpatient setting," Dr. Bates said.

Nonpreventable reactions included skin rashes in patients with a previously unknown penicillin allergy. Preventable ones included bleeding in patients on blood thinners, blamed on inadequate patient monitoring or interactions with other drugs. Heart drugs, diuretics and pain relievers were among the most commonly implicated drugs.

Some of the problems resulted from drug interactions and occurred because patients had several prescriptions from more than one doctor. A computerized system of the sort used in some hospitals could alert doctors to outpatients who should avoid a certain drug, Dr. Gurwitz said. Patients could also help by bringing all their prescriptions to all doctors' visits, he said.

Incidence and Preventability of Adverse Drug Events 
Among Older Persons in the Ambulatory Setting 

JAMA v.289, n.9, 5mar03

Jerry H. Gurwitz, MD; Terry S. Field, DSc; Leslie R. Harrold, MD, MPH; Jeffrey Rothschild, MD, MPH; Kristin Debellis, PharmD; Andrew C. Seger, RPh; Cynthia Cadoret; Leslie S. Fish, PharmD; Lawrence Garber, MD; Michael Kelleher, MD; David W. Bates, MD, MSc

• Index of Figures and Tables: http://jama.ama-assn.org/issues/v289n9/fig_tab/joc21714_ft.html

Context Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting.

Objective To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting.

Design, Setting, and Patients Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors.

Main Outcome Measures Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable.

Results There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events.

Conclusions Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.

JAMA. 2003;289:1107-1116

source: http://jama.ama-assn.org/issues/v289n9/rfull/joc21714.html#box1 4mar03