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Dubin I, Schattner A. Reversible iatrogenic paraparesis secondary to masked hypokalaemia in thrombocytosis-associated pseudohyperkalaemia. BMJ Case Rep 2019; 12:12/3/e228058. [PMID: 30904892 DOI: 10.1136/bcr-2018-228058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An elderly patient who presented with recent recurrent falls was admitted, reporting inability to stand and recent acute diarrhoeal illness. Paraparesis was diagnosed but extensive investigations did not elucidate its cause. He had atherosclerotic cardiac and vascular disease, diabetes, hypertension, chronic kidney disease and pancreatectomy/splenectomy for a lesion that turned out to be benign. He was receiving multiple medications including kayexalate, which was started a few weeks prior, and the dose increased, due to hyperkalaemia up to 6.3 mEq/L. Although the postsplenectomy thrombocytosis was not striking (700×109/L), spurious hyperkalaemia (pseudohyperkalaemia) was suspected when no cause of hyperkalaemia could be identified and widely fluctuating serum potassium levels were noted. Concurrent K+ determination in the serum and plasma revealed that the patient actually had significant masked hypokalaemia (2.4 mEq/L). Once kayexalate was stopped and normokalaemia (in plasma) achieved by replacement therapy, paraparesis completely resolved (5/5 muscle strength) and no more falls occurred after discharge.
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Affiliation(s)
- Ina Dubin
- Sanz Medical Centre, Laniado Hospital, Netanya, Israel
| | - Ami Schattner
- Sanz Medical Centre, Laniado Hospital, Netanya, Israel.,Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Mühlbauer B, Madea B. Behandlungsfehlervorwürfe bei Arzneimitteltherapie. Rechtsmedizin (Berl) 2015. [DOI: 10.1007/s00194-015-0018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Cutaneous drug eruptions can range from an asymptomatic rash to a life-threatening emergency. Because of the high frequency, morbidity, and potential mortality associated with drug eruptions, patients with possible drug reactions should promptly be recognized, worked up, and treated. Drug reactions are common in the elderly population due to age-related alterations in metabolism, excretion of medications, and polypharmacy. This review discusses the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of drug eruptions that providers commonly encounter in the care of the geriatric population. An algorithm for an approach to patients with a suspected drug eruption is presented.
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Affiliation(s)
- Ammar M Ahmed
- Department of Dermatology, University of Texas-Southwestern Medical Center-Austin Campus, University Medical Center Brackenridge, Seton Healthcare Family, 601 East 15th Street, CEC C2.443, Austin, TX 78701, USA.
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Bogé A, Lorgis L, Dautriche A, Bonnet M, Gudjoncik A, Buffet P, L'Huillier I, Zeller M, Sgro C, Cottin Y. [Admissions to a coronary care unit for severe iatrogenic conditions: a prospective study of 7244 patients]. Ann Cardiol Angeiol (Paris) 2012. [PMID: 23177059 DOI: 10.1016/j.ancard.2012.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Iatrogenic complications are defined as adverse drug reactions or complications induced by non-drug interventions, such as cardiac devices or stimulation techniques. Iatrogenic complications occurring during hospital stay are known to be associated with increased hospital length of stay and mortality. Only few data are available on iatrogenic as cause of hospital admission, particularly in coronary care unit. In patient admitted in coronary care unit for iatrogenic, we aimed: (a) to analyse their prevalence, type and characteristics, (b) to analyse their in-hospital length of stay and mortality and (c) to evaluate the predictive factors of severity and mortality. METHODS From 1st April 2008 to 31 January 2012, all the consecutive admissions caused by iatrogenic complications at the coronary care unit were prospectively included and classified in two groups: (1) pharmacological iatrogenic (beta-blockers, digoxin, calcium channel blockers, cordarone, several antiarrhythmic , anticoagulants, antiplatelets and others), (2) non-pharmacological iatrogenic (pacemaker, cardioverter-defibrillator, radiofrequency, coronary angiography and cardiac surgery including valve surgery). We excluded patients with intentional overdose. We also compared patients according to the severity (group 1: patients who just need a monitoring; and group 2: patients for whom there was invasive procedure or for whom we used vasoactive amine). RESULTS Among 7244 patients admitted in coronary care unit during the inclusion period, 250 (3.4%) were admitted for iatrogenic complication, 136 in pharmacological group and 114 in non-pharmacological group. In non-pharmacological group, there was more men: 73.7% vs. 47.8% (P < 0.001), patients are younger: 67.3 ± 13.2 vs. 75.4 ± 15.8 (P < 0.001) and are more severe: 80.4% in group 2 vs. 69.4% (P = 0.05). The mortality in this group tends to be more important. According to the severity, there is no difference about drugs: 7.4 ± 3.4 vs. 6.8 ± 2.9 (P = 0.184) and are staying longer in hospital: 4.7 ± 3.2 days vs. 3.4 ± 2.4 (P = 0.009) for coronary care unit length of stay and 15 ± 13.7 vs. 10 ± 9.8 (P = 0.003) for total length of stay. CONCLUSION Iatrogenic represent a non-negligible cause of admission in coronary care unit, which associated with significant mortality (8.8%) and with a trend toward a higher length of stay. Further studies are needed to determinate the origin of mortality and to better characterize patients at risk of iatrogenic.
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Affiliation(s)
- A Bogé
- Service de cardiologie, CHU Bocage, boulevard Maréchal-de-Lattre-de-Tassigny, 21034 Dijon cedex, France
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Chen Q, Borzecki AM, Cevasco M, Shin MH, Shwartz M, Itani KMF, Rosen AK. Examining the relationship between processes of care and selected AHRQ patient safety indicators postoperative wound dehiscence and accidental puncture or laceration using the VA electronic medical record. Am J Med Qual 2012; 28:206-13. [PMID: 23007377 DOI: 10.1177/1062860612459070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examines whether Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) Postoperative Wound Dehiscence (PWD) and Accidental Puncture or Laceration (APL) events reflect problems with hospital processes of care (POC). The authors randomly selected 112 PSI-flagged PWD/APL discharges from 2002-2007 VA administrative data, identified true cases using chart review, and matched cases with controls. This yielded a total of 95 case-control pairs per PSI. Patient information and clinical processes on each case-control pair were abstracted from the electronic medical record (EMR). Although PWD cases and controls differed on incision and closure types, APL cases and controls were comparable in examined processes. Further exploration of the process differences between PWD cases and controls indicated that they were primarily caused by patients' underlying surgical problems rather than quality of care shortfalls. Documentation of POC was frequently missing in EMRs. Future studies should combine EMR review with alternative approaches, such as direct observation, to better assess POC.
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Affiliation(s)
- Qi Chen
- VA Boston Healthcare System, Boston, MA 02130, USA.
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Taché SV, Sönnichsen A, Ashcroft DM. Prevalence of adverse drug events in ambulatory care: a systematic review. Ann Pharmacother 2011; 45:977-89. [PMID: 21693697 DOI: 10.1345/aph.1p627] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Most medications are prescribed, dispensed, and administered in ambulatory care settings, yet little information exists on the adverse effects of drugs in this setting. This review was conducted to estimate the prevalence of adverse drug events (ADEs) and the proportion of preventable ADEs in ambulatory care settings; compare data for different age groups including children, adults, and elderly patients; and review drug classes most commonly associated with ADEs. DATA SOURCES Four electronic databases-PubMed (1966-March 2011), International Pharmaceutical Abstracts (1970-March 2011), EMBASE (1980-March 2011), and the Cochrane Database of Systematic Reviews (1993-March 2011)-were systematically searched for published data. Bibliographies of retrieved articles were searched individually for additional relevant studies. STUDY SELECTION A standardized definition of an ADE was used to select studies in populations living in the community, with medical visits to primary care facilities, nonspecialty ambulatory care facilities, and/or admissions to a hospital for medication-related adverse events. DATA EXTRACTION Data were extracted using a standardized table. Forty-three studies met our inclusion criteria. DATA SYNTHESIS The median ADE prevalence rate for retrospective studies was 3.3% (interquartile range [IQR] 2.3-7.1%) vs 9.65% (IQR 3.3-17.35%) for prospective studies. Median preventable ADE rates in ambulatory care-based studies were 16.5%, and 52.9% for hospital-based studies. Median prevalence rates by age group ranged from 2.45% for children to 5.27% for adults, 16.1% for elderly patients, and 3.45% for studies including all ages. CONCLUSIONS Despite a recent increase in publications on ADEs in the ambulatory care setting, most studies remain hospital based. Notable differences in prevalence rates by age groups and by responsible drug categories provide guidance on how to direct attention toward effective targets for improvement of medication safety in ambulatory care settings.
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Affiliation(s)
- Stephanie V Taché
- Department of Family and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.
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Zapatero Gaviria A, Barba R, Ruiz Giardin J, Emilio Losa Garcia J, Marco Martinez J, Plaza Canteli S, Canora Lebrato J. Acontecimientos adversos causados por medicamentos en pacientes ingresados en medicina interna. Rev Clin Esp 2010; 210:263-9. [DOI: 10.1016/j.rce.2009.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 12/01/2009] [Accepted: 12/20/2009] [Indexed: 11/24/2022]
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Mercier E, Giraudeau B, Giniès G, Perrotin D, Dequin PF. Iatrogenic events contributing to ICU admission: a prospective study. Intensive Care Med 2010; 36:1033-7. [PMID: 20217046 DOI: 10.1007/s00134-010-1793-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 11/21/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the incidence, risk factors, severity, and preventability of iatrogenic events (IEs) as a cause of intensive care unit (ICU) admission. DESIGN Comparison of patients admitted or not for IE. IE was diagnosed after assessing independently predefined criteria. SETTING The ICU of a teaching hospital. PATIENTS All patients consecutively admitted over 6 months. INTERVENTIONS None. MEASUREMENTS AND RESULTS Characteristics of patients, supportive treatments, length of stay, and outcomes were recorded. For patients admitted for IE, cause, origin, and preventability of IE were assessed by consensus. Of 528 patients, 103 (19.5%) were admitted for IE. Their Simplified Acute Physiology Score (SAPS) II was higher (41.2 +/- 22.6 versus 31.4 +/- 18.6), as was their Logistic Organ Dysfunction (LOD) score. Surgical admissions and admission for shock were more frequent. The main risk factors were age, underlying disease, low Mac Cabe or Knaus score, number of physicians treating the patient, number of drugs prescribed, and other hospitalization within 1 month. Length of stay was higher (11.1 days versus 7.9 days, 0.5-6.0, p = 0.02). Catecholamine drugs, blood transfusion, and parenteral nutrition were more frequently required in the IE group. ICU mortality was 15.5% in the IE group and 11.3% in the group without IEs [not significant (ns) after adjustment]. IE was considered as probably preventable in 73.8% of cases. CONCLUSION Of admissions to the ICU, 19.5% resulted from IE, with high proportion of shock, leading to greater need for invasive treatments and longer stay in the ICU. Most cases of IE seemed preventable.
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Affiliation(s)
- Emmanuelle Mercier
- Service de Réanimation Médicale, Université François Rabelais, Hôpital Bretonneau, CHRU, 37044, Tours Cedex 9, France.
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Leendertse AJ, Visser D, Egberts AC, van den Bemt PM. The Relationship Between Study Characteristics and the Prevalence of Medication-Related Hospitalizations. Drug Saf 2010; 33:233-44. [DOI: 10.2165/11319030-000000000-00000] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Jonville-Béra AP, Saissi H, Bensouda-Grimaldi L, Beau-Salinas F, Cissoko H, Giraudeau B, Autret-Leca E. Avoidability of Adverse Drug Reactions Spontaneously Reported to a French Regional Drug Monitoring Centre. Drug Saf 2009; 32:429-40. [DOI: 10.2165/00002018-200932050-00006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Sullivan KM, Spooner LM. Adverse-drug-reaction reporting by pharmacy students in a teaching hospital. Am J Health Syst Pharm 2008; 65:1177-9. [PMID: 18541689 DOI: 10.2146/ajhp070307] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Adverse-drug-reaction (ADR) reporting by pharmacy students in a teaching hospital is described. SUMMARY Faculty and pharmacy staff collaborated to modify the existing data collection form for suspected ADRs. During the orientation session for each new rotation, pharmacy students received an overview of ADRs, ADR trigger medications, and the hospital's ADR reporting program. Pharmacy students collected ADR data by prospectively and retrospectively reviewing inpatient charts for suspected ADRs that were identified through various means. The students were responsible for completely and accurately documenting all aspects of the suspected ADRs. At least once a week, patient charts were requested to aid students in their investigation of suspected ADRs. Data from patient cases involving allergy-related ADRs were confirmed and updated in the hospital's computer system. All documented ADRs were entered into a spreadsheet for the purpose of generating quarterly reports. Report data were analyzed by faculty and students to identify hospitalwide trends in an effort to develop new ADR prevention strategies. Pharmacy student involvement with the ADR process began in January 2006. A total of 310 ADRs were documented for 2006, compared with 42 for 2005, when pharmacy students were not involved in data collection. ADR reports also led to allergy updates for 42 patients. With students collecting and analyzing ADR data, the hospital was able to recognize those medications that commonly caused ADRs and track hospitalwide trends in an effort to target new initiatives to prevent their occurrence. CONCLUSION Pharmacy student participation in the ADR reporting program led to a significant increase in the number of ADRs documented.
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Affiliation(s)
- Karyn M Sullivan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, MA 01608, USA.
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Green CF, Mottram DR, Rowe PH, Pirmohamed M. Adverse drug reactions as a cause of admission to an acute medical assessment unit: a pilot study. J Clin Pharm Ther 2008. [DOI: 10.1111/j.1365-2710.2000.00298.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Franke L, Avery AJ, Groom L, Horsfield P. Is there a role for computerized decision support for drug dosing in general practice? A questionnaire survey. J Clin Pharm Ther 2008. [DOI: 10.1111/j.1365-2710.2000.00303.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Laroche ML, Boqueho S, Vallejo C, Nouaille Y, Godard S, Merle L. Effets indésirables médicamenteux aux urgences : une étude prospective au CHU de Limoges. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.jeur.2008.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Thomsen LA, Winterstein AG, Søndergaard B, Haugbølle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007; 41:1411-26. [PMID: 17666582 DOI: 10.1345/aph.1h658] [Citation(s) in RCA: 261] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To estimate the incidence and describe characteristics of preventable adverse drug events (pADEs) in ambulatory care. DATA SOURCES Studies were searched in PubMed (1966-March 2007), International Pharmaceutical Abstracts (1970-December 2006), the Cochrane database of systematic reviews (1993-March 2007), EMBASE (1980-February 2007), and Web of Science (1945-March 2007). Key words included medication error, adverse drug reaction, iatrogenic disease, outpatient, ambulatory care, primary health care, general practice, patient admission, hospitalization, observational study, retrospective studies, health services research, and follow-up studies. Additional articles were found in the reference sections of retrieved articles. STUDY SELECTION AND DATA EXTRACTION Peer-reviewed articles assessing pADEs in ambulatory care, with detailed descriptions/frequency distributions of (1) ADE/pADE incidence, (2) clinical outcomes, (3) associated drug groups, and/or (4) underlying medication errors were included. Study country, year and design, sample size, follow-up time, ADE/pADE identification method, proportion of ADEs/pADEs and ADEs/pADEs requiring hospital admission, and frequency distribution of adverse outcome, associated drug groups, or medication errors were extracted. DATA SYNTHESIS Twenty-nine studies met inclusion criteria: 14 were ambulatory-based and 15 were hospital-based. Seven studies enrolled only elderly patients. The median ADE incidence was 14.9 (range 4.0-91.3) per 1000 person-months, and the pADE incidence was 5.6 per 1000 person-months (1.1-10.1). The median ADE preventability rate was 21% (11-38%). The median incidence of ADEs requiring hospital admission was 0.45 (0.10-13.1) per 1000 person-months, and the median incidence of pADEs requiring hospital admission was 4.5 per 1000 person-months. Cardiovascular drugs, analgesics, and hypoglycemic agents together accounted for 86.5% of pADEs, and 77.2% of pADEs resulted in symptoms of the central nervous system, electrolyte/renal system, and gastrointestinal tract. Medication errors resulting in pADEs occurred in the prescribing and monitoring stages. The most frequent drug therapy problem and error of commission reported in ambulatory-based studies on pADEs was the use of inappropriate drugs (42.7%; 40.4-45%). For pADEs requiring hospital admission, the most frequent drug therapy problem and error of omission reported was inadequate monitoring (45.4%; range 22.2-69.8%). Failure to prescribe prophylaxis to patients taking nonsteroidal antiinflammatory drugs or antiplatelet drugs frequently caused gastrointestinal toxicity, whereas lack of monitoring of diuretic, hypoglycemic, and anticoagulant use caused over- or under-diuresis, hyper- or hypoglycemia, and bleeding. CONCLUSIONS ADEs in ambulatory care are common, with many being preventable and many resulting in hospitalization. Quality improvement programs should target errors in prescribing and monitoring, especially for patients using cardiovascular, analgesic, and hypoglycemic agents.
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Affiliation(s)
- Linda Aagaard Thomsen
- Section for Social Pharmacy, Faculty of Pharmaceutical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Izzedine H, Launay-Vacher V, Deybach C, Bourry E, Barrou B, Deray G. Drug-induced diabetes mellitus. Expert Opin Drug Saf 2006; 4:1097-109. [PMID: 16255667 DOI: 10.1517/14740338.4.6.1097] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To review the medications that influence glucose metabolism with a focus on hypertensive, transplant and HIV-infected patient populations. METHODS Literature obtained from a MEDLINE search from 1970 to present, including studies published in the English language. The search strategy linked drugs, hyperglycaemia and diabetes mellitus, HIV, transplantation, hypertension and psychiatric patients. RESULTS Many common therapeutic agents influence glucose metabolism. Multiple mechanisms of action on glucose metabolism exist through pancreatic, hepatic and peripheral effects. The prevalence of hyperglycaemia was higher with the use of thiazide diuretic, beta-blocker, calcineurin, protease inhibitors and atypical antipsychotic drugs. CONCLUSIONS Patients treated with those drugs appear to be at increased risk for developing diabetes. It is prudent to monitor plasma glucose values when it is not possible to avoid prescription of medication with known effects on carbohydrate metabolism.
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Affiliation(s)
- Hassane Izzedine
- Department of Nephrology, Pitie-SalPetriere Hospital, Paris, France.
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Mcdonnell PJ. The $181,000 Adverse Drug Reaction. Hosp Pharm 2004. [DOI: 10.1177/001857870403900706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reports the case of a 52-year-old male, status post-heart transplant, who was admitted to the hospital with profound pancytopenia. The cause was an adverse drug reaction, specifically the well-established drug interaction between allopurinol and azathioprine. This reaction was severe and costly, with total charges of $181,000 incurred during the patient's 31-day hospital stay. The annual cost of drug-related morbidity and mortality exceeds $136 billion. Adverse drug events can be classified variously; two common categories are adverse drug reactions and medication errors. If an adverse drug reaction is determined to be preventable, it can be classified as a medication error. Factors that determine preventability include whether a known drug-drug interaction was involved in the event and whether health care providers made efforts to avoid this interaction through increased monitoring or dose adjustments. Pharmacist intervention and increased vigilance can decrease the occurrence of such events. Furthermore, pharmacists who are aware of preventability factors involved in adverse drug events can become proactive leaders in the area of medication safety.
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Schattner A, Fletcher RH. Pearls and Pitfalls in Patient Care: Need to Revive Traditional Clinical Values. Am J Med Sci 2004; 327:79-85. [PMID: 14770024 DOI: 10.1097/00000441-200402000-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Medicine has achieved phenomenal progress in recent years, yet there is ample evidence of dysfunction, reflected in persistently high rates of misdiagnosis, frequent iatrogenic illness, the popularity of 'alternative' medicine, and rising healthcare costs. An urgent need for a change is indicated. True adherence to basic clinical and personal values may avoid significant pitfalls in patient care. These include the immense value of a really careful history and physical examination; the wealth of information that can be obtained through patient's families, physicians, past records, and a search of electronic databases for the best evidence; restraint in management decisions; making the most of simple preventive measures and effective nonpharmacological interventions; appropriate "bed-to-door" intervals; a more personal care of the patient as a unique person, paying more attention to emotional factors that affect medical illness; constructive management of medical errors; and humility. The great potential of the many recent advances in medicine may be more fully realized if we accept that new capabilities should complement, not replace, old values and skills, which still make the essential foundation for medical decision making and patient care.
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Affiliation(s)
- Ami Schattner
- Hebrew University and Hadassah Medical School, Kaplan Medical Center, Jerusalem, Israel.
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Affiliation(s)
- James H Herndon
- Department of Orthopaedics, Massachusetts General Hospital, Boston 02114, USA.
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Dormann H, Criegee-Rieck M, Neubert A, Egger T, Geise A, Krebs S, Schneider T, Levy M, Hahn E, Brune K. Lack of awareness of community-acquired adverse drug reactions upon hospital admission : dimensions and consequences of a dilemma. Drug Saf 2003; 26:353-62. [PMID: 12650635 DOI: 10.2165/00002018-200326050-00004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Adverse drug reactions (ADRs) are a well-known cause of hospital admission. Nevertheless a quantitative estimate of the preventability of and physicians' awareness of these reactions is lacking. STUDY DESIGN AND METHODS Using intensive bedside and computer-assisted drug surveillance methods a 13-month prospective pharmacoepidemiological survey was carried out on patients admitted to two medical wards of the Erlangen-Nuremberg University Hospital in Erlangen, Germany. This study aimed to define the incidence of preventable and unavoidable ADRs. In addition we investigated the awareness of the physicians to ADRs at the time of admission and the rate of contraindicated pre-admission prescriptions. RESULTS In 78 (8.5%) of 915 (10.9%) admissions a total of 102 (42 preventable) community-acquired ADRs were detected on admission. In 45 (3.8%) of the admissions ADRs led directly to hospitalisation. 56.9% of the ADRs were not recognised by the attending physician on admission. Marked correlation was found between the awareness of ADRs and their probability and severity scores (r = 0.85 and r = 0.94, respectively; p < 0.05). The most frequently detected ADRs were due to direct toxicity and secondary pharmacological effects. Idiosyncratic reactions were often missed and 18.6% of all drugs prescribed prior to admission were contraindicated. Leading the list were diuretics, analgesics/NSAIDs and antipsychotics/sedatives. CONCLUSIONS Awareness of existing ADRs on hospital admission and appropriate prescribing prior to hospital admission require attention. Early detection of ADRs on hospital admission can be achieved by the use of computer support systems. Many ADRs could be prevented by adhering to indications and contraindications.
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Affiliation(s)
- Harald Dormann
- Department of Internal Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany.
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Abstract
OBJECTIVE To describe the process that has been undertaken to (i) validate further UK indicators for preventable drug-related morbidity (PDRM) generated by a previous study and (ii) develop additional new indicators derived from UK clinical practice. DESIGN A two-round Delphi questionnaire survey. SETTING A UK study based in primary care. PARTICIPANTS A purposively selected sample of primary care pharmacists (n = 9) and general practitioners (n = 8). OUTCOME MEASURES The establishment of consensus among the panel as to whether an indicator represented a PDRM. RESULTS The pre-defined level of consensus was achieved for 24 indicators (59%; 24 of 41). CONCLUSIONS We have identified that although mechanisms exist for identifying 'the outcome' component of PDRM indicators, identifying the 'pattern of care' that is needed to prevent their occurrence is far more challenging. Nonetheless, we have taken considerable steps along the path of validating such indicators. Future operationalization in a general practice setting should help to facilitate improvements in medicine management in primary care and ultimately benefit patients.
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Affiliation(s)
- C J Morris
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester, UK.
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Etemad LR, Hay JW. Cost-effectiveness analysis of pharmaceutical care in a medicare drug benefit program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2003; 6:425-435. [PMID: 12859583 DOI: 10.1046/j.1524-4733.2003.64255.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES Although there has recently been substantial interest in a Medicare drug benefit program, little attention has focused on ensuring improved access to medication monitoring for Medicare beneficiaries. Using a societal perspective, we evaluated the impact pharmacists could have on inappropriate prescribing, patient compliance, and medication-related morbidity and mortality within a Medicare drug benefits program. METHODS A cost-effectiveness analysis from a societal perspective was performed. A comprehensive MEDLINE search for relevant literature identified data sources and model parameters. RESULTS In the base case, a pharmaceutical care benefit in the elderly population would cost US dollars 2100 (year 2000 prices) per life-year saved, which is highly cost-effective. Reasonable changes in model parameters did not raise the cost-effectiveness ratio above US dollars 13000 per life-year saved. CONCLUSION Despite limitations in both the quantity and the specificity of data available, pharmaceutical care appears to be a highly cost-effective augmentation to a Medicare drug benefit program. This result is robust to model parameter changes. This model is conservative in that it does not include ongoing benefits from medication monitoring or increased elderly drug utilization and polypharmacy as the Medicare drug program is phased in.
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Affiliation(s)
- Lida R Etemad
- Economic and Outcomes Research, Ingenix, Eden Prairie, MN, USA
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Schatz R, Belloto RJ, White DB, Bachmann K. Provision of drug information to patients by pharmacists: the impact of the Omnibus Budget Reconciliation Act of 1990 a decade later. Am J Ther 2003; 10:93-103. [PMID: 12629587 DOI: 10.1097/00045391-200303000-00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Drug-related illness in the United States factors substantially in health care costs, although often these illnesses and their attendant costs are preventable. One strategy for minimizing adverse drug reactions is to provide drug information to consumers in the form of prescription counseling at pharmacies. The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) contained provisions for mandating such counseling to Medicaid patients. OBRA 1990 was implemented in 1993, but most states acted quickly to extend counseling services to all patients receiving prescription drugs. We looked at the extent and quality of prescription counseling available in community pharmacies 1 decade after OBRA 1990 was written. We evaluated the counseling services afforded at large chain pharmacies, independent community pharmacies, and on-line pharmacies for a hydrochlorothiazide prescription. We found that most (69%) pharmacies offered to provide prescription counseling service, and that average counseling index scores, a measure of the quality or extent of information provided as determined by a Rasch analysis, were generally satisfactory. Our observations based on a single prescription for hydrochlorothiazide, along with other studies, suggest that there is a positive upward trend in the number of pharmacies providing prescription drug information, and that the extent of information provided suggests that the objectives of OBRA 1990 and related legislation to reduce ADRs are being fundamentally satisfied.
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Affiliation(s)
- Robin Schatz
- Department of Pharmacology, College of Pharmacy, The University of Toledo, 2801 W. Bancroft Street, Toledo, OH 43606, USA
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Vargas E, Terleira A, Hernando F, Perez E, Cordón C, Moreno A, Portolés A, Hernando F. Effect of adverse drug reactions on length of stay in surgical intensive care units. Crit Care Med 2003; 31:694-8. [PMID: 12626971 DOI: 10.1097/01.ccm.0000049947.80131.ed] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the frequency of adverse drug reactions in surgical intensive care units and evaluate their effect on the length of stay. DESIGN Prospective cohort study. Between May 1997 and December 1999, while the patients were staying in the surgical intensive care unit, data were gathered regarding suspected adverse drug reactions and on different variables related to the length of stay. SETTING Surgical intensive care units of our hospital. PATIENTS A total of 401 patients hospitalized in the surgical intensive care unit. MAIN RESULTS In 37 of the 401 patients seen (9.2%; 95% confidence interval, 6.6-12.5), 39 different adverse drug reactions were detected. The adverse drug reactions were most frequently caused by the following drugs: morphine hydrochloride (n = 13), meperidine hydrochloride (n = 9), and metamizole (n = 7). Five adverse drug reactions were severe, the suspected medication had to be discontinued in 14 cases, and new drugs were necessary to manage the adverse drug reaction in 28 cases. The crude estimation of the effect of adverse drug reactions performed on the length of stay with a bivariant regression model indicated that each adverse drug reaction was related to an increase of 3.39 days (95% confidence interval, 1.47-5.31) in the length of stay. This estimation was reduced to 2.31 days (95% confidence interval, 0.64-3.99) when considering other variables that might cause confusion for analysis, although it is still important. CONCLUSIONS Adverse drug reactions are a significant clinical and economic problem in surgical intensive care units.
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Affiliation(s)
- Emilio Vargas
- Clinical Pharmacology Service, Hospital Clínico San Carlos, Madrid, Spain
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Bednall R, McRobbie D, Hicks A. Identification of medication-related attendances at an A & E department. J Clin Pharm Ther 2003; 28:41-5. [PMID: 12605617 DOI: 10.1046/j.0269-4727.2003.00461.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of medication is the most common medical intervention, but it has associated risks. These have been described as drug-related problems (DRPs). Other non-UK studies have reported DRPs to be the cause of 3-16% of hospital admissions and around 4% of attendances at emergency departments. The size of the problem in the UK has not been quantified. AIM The aim of this study was to identify the number of patients attending a central London accident and emergency (A & E) department with symptoms or conditions caused by DRPs. METHOD A 2-week retrospective, case-review study was conducted in the A & E department of St Thomas' Hospital, London, during March 1999. DRPs were identified using recognized criteria. Statistical analysis identified patient characteristics which could be associated with the incidence of DRPs. The types of DRP and the drugs involved were identified. RESULTS During the study period, 106 patients attended the A & E department with a DRP. This equates to 4% of the A & E population. During this period the demographics of the A & E attenders were no different to the annual A & E cohort. The most common DRPs were adverse drug reactions and overdose. The most frequently involved drugs included analgesics, antibiotics, those with narrow therapeutic indices and illegal drugs. The mean age of this patient group was 38 years (non-significant). They attended significantly more frequently during the early hours of the morning and on Saturdays than the A & E general population (chi-squared P = 0.004 and P = 0.003, respectively). DISCUSSION The incidence of DRP as a cause of attendance at A & E reflects that in the literature. No statistical association with a specific age group of patients could be made, but the mean age of 38 years is younger than previously reported. The demographic differences which were statistically significant can be explained by the increased incidence of DRP associated with the use of illegal drugs than reported in other studies. Other drug groups identified by this study are representative of other reports. CONCLUSION DRPs account for 4% of attendances at a central London A & E Department.
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Affiliation(s)
- R Bednall
- General Medicine, A & E Department, Guy's & St Thomas' Hospital NHS Trust, London, UK.
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Morrissey EF, McElnay JC, Scott M, McConnell BJ. Influence of Drugs, Demographics and Medical History on Hospital Readmission of Elderly Patients. Clin Drug Investig 2003. [DOI: 10.2165/00044011-200323020-00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
Computerized physician-order entry (CPOE) is a system of hardware and software through which a physician enters orders directly into a computer rather than writing them on paper. The advantages of CPOE include order legibility, improved response time, reduction in adverse drug reactions, reduced cost of care, and improved patient outcomes. The maturation of mobile computing platforms, graphical user interfaces, and wireless technologies are making CPOE more practical for both outpatient and inpatient care. Significant barriers to the implementation of CPOE include the reluctance of physicians to change existing practices, doubt about the possible benefits, increased front-end time to enter orders, and system cost.
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Affiliation(s)
- Runi A Foster
- Division of Pulmonary and Critical Care Medicine, University of Florida College of Medicine, PO Box 100225, Gainesville, FL 32610-0225, USA.
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McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother 2002; 36:1331-6. [PMID: 12196047 DOI: 10.1345/aph.1a333] [Citation(s) in RCA: 333] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) are a significant cause of hospital admissions. These events can lead to significant morbidity and mortality and financial costs. ADRs that may be preventable might be considered a form of medication error. OBJECTIVE To assess the potential preventability of ADRs directly related to a patient's hospital admission. METHODS A retrospective chart review of 437 ADRs occurring during an 11-month period was conducted at a university hospital. A subset of these events leading to hospital admissions was identified for further review. Those that resulted in admission were further examined to determine probability of causality, severity, and preventability. RESULTS Over 11 months, 158 ADRs were directly related to hospital admission. The relationship of these admissions to drug exposure was determined to be probable or highly probable in 154 (97.4%) of these cases. From this group, 96 (62.3%) of these events were considered potentially preventable, with 23 (24%) considered severe to life-threatening. Characteristics associated with these ADRs included documentation of a toxic drug concentration or abnormal laboratory value (80%), inadequate monitoring of a patient's drug therapy (67%), inappropriate dose (51%), patient noncompliance (33%), drug-drug interaction (26%), contraindication to therapy (3%), and documented allergy (1%). These ADRs resulted in 595 hospital days, with an average length of stay of 6.1 days. CONCLUSIONS ADRs leading to hospital admissions are often preventable. Approximately 25% of these events were serious to life-threatening. Most resulted from inadequate monitoring of therapy or inappropriate dosing. Patient noncompliance and drug interactions were also common causes. Multidisciplinary prevention strategies among physicians, pharmacists, other healthcare professionals, and patients focusing on communication and education should be targeted.
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Winterstein AG, Sauer BC, Hepler CD, Poole C. Preventable drug-related hospital admissions. Ann Pharmacother 2002; 36:1238-48. [PMID: 12086559 DOI: 10.1345/aph.1a225] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To estimate the prevalence of preventable drug-related hospital admissions (PDRAs) and to explore if selected study characteristics affect prevalence estimates. METHODS Keyword search of MEDLINE (1966-December 1999), International Pharmaceutical Abstracts (1970-December 1999), and hand search. Two reviewers independently selected studies published in peer-reviewed journals and extracted crude prevalence estimates and study characteristics. Trials had to specifically address consequences of drug therapy requiring hospital admission and include a quantitative preventability assessment. Stratified analysis and meta-regression were used to explore the association between study characteristics and prevalence estimates. DATA SYNTHESIS Fifteen studies reported a median PDRA prevalence of 4.3% (interquartile range [IQR] 3.1-9.5%). The median preventability rate of drug-related admissions was 59% (IQR 50-73%). No evidence of publication bias related to study size could be determined. Because the individual study results were highly heterogeneous (Cochran's Q = 176, df = 14; p < 0.001), no meta-analytic summary estimate was computed. Stratified analysis suggested an association between prevalence estimates and 3 study characteristics: exclusion of first admissions (readmission studies: average PDRA prevalence of 14.0 %, estimated prevalence OR = 3.7); mean age of admissions >70 (OR = 2.1); and inclusion of "indirect" drug-related morbidity, such as omission errors or therapeutic failure (OR = 1.9). There was little evidence of other associations with prevalence estimates, such as selection of specific hospital units, exclusion/inclusion of planned admissions, country, and specified methods of PDRA case ascertainment. CONCLUSIONS Drug-related morbidity is a significant healthcare problem, and a great proportion is preventable. Study methods in prevalence reports vary and should be considered when interpreting findings or planning future research.
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Affiliation(s)
- Almut G Winterstein
- Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, Gainesville, FL 32610-0496, USA.
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Abstract
The elderly are at higher risk for suffering the annoying and hazardous skin reactions that are associated with drug therapy. If a serious reaction occurs, the aged are also at higher risk for major morbidity and mortality compared with younger individuals. Early consideration of a drug cause and prompt cessation of all potentially associated drugs may improve a patient's outcome. Thus, a prompt, careful, and accurate characterization of a drug-related reaction is important in optimizing patient care, along with close monitoring for associated internal toxicities and other medical complications of severe cutaneous reactions.
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Affiliation(s)
- John R Sullivan
- Drug Safety Clinic, Department of Medicine, University of Toronto Medical School, Ontario, Canada
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Jha AK, Kuperman GJ, Rittenberg E, Teich JM, Bates DW. Identifying hospital admissions due to adverse drug events using a computer-based monitor. Pharmacoepidemiol Drug Saf 2001; 10:113-9. [PMID: 11499849 DOI: 10.1002/pds.568] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hospital admissions due to adverse drug events (ADEs) are expensive, and many may be preventable, yet few institutions have ongoing surveillance for these events. OBJECTIVE To evaluate the use of a computer-based ADE monitor to identify admissions due to ADEs and to measure the associated costs. DESIGN Prospective cohort study in one tertiary care hospital. PARTICIPANTS All patients admitted to nine medical and surgical units in a tertiary care hospital over an 8-month period. MAIN OUTCOME MEASURE Admissions to the hospital due to an adverse drug event. METHODS A computer-based monitoring program generated alerts suggesting that an ADE might be present. A trained reviewer then evaluated the record. RESULTS Among the 3238 admissions, 76 (2.3%, 1.4% after adjusting for sampling) were found to be caused by an ADE. Of these ADEs, 78% were severe and 28% were preventable. Estimated costs were $16,177 per ADE, and $10,375 per preventable ADE; annualized costs to the hospital were $6.3 million per year for all ADEs, and $1.2 million for preventable ADEs. CONCLUSIONS Many admissions were caused by ADEs, although our point estimate undoubtedly represents a lower bound. These events were mostly severe, often preventable, and expensive. The computer-based monitoring system represents a practical approach for identifying ADEs that occur in outpatients and cause admission to the hospital.
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Affiliation(s)
- A K Jha
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School 02115, USA
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Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION (WASHINGTON, D.C. : 1996) 2001; 41:192-9. [PMID: 11297331 DOI: 10.1016/s1086-5802(16)31229-3] [Citation(s) in RCA: 399] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To update the 1995 estimate of $76.6 billion for the annual cost of drug-related morbidity and mortality resulting from drug-related problems (DRPs) in the ambulatory setting in the United States to reflect current treatment patterns and costs. DESIGN For this study, we employed the decision-analytic model developed by Johnson and Bootman. We used the model's original design and probability data, but used updated cost estimates derived from the current medical and pharmaceutical literature. Sensitivity analyses were performed on cost data and on probability estimates. SETTING Ambulatory care environment in the United States in the year 2000. PATIENTS AND OTHER PARTICIPANTS A hypothetical cohort of ambulatory patients. MAIN OUTCOME MEASURES Average cost of health care resources needed to manage DRPs. RESULTS As estimated using the decision-tree model, the mean cost for a treatment failure was $977. For a new medical problem, the mean cost was $1,105, and the cost of a combined treatment failure and resulting new medical problem was $1,488. Overall, the cost of drug-related morbidity and mortality exceeded $177.4 billion in 2000. Hospital admissions accounted for nearly 70% ($121.5 billion) of total costs, followed by long-term-care admissions, which accounted for 18% ($32.8 billion). CONCLUSION Since 1995, the costs associated with DRPs have more than doubled. Given the economic and medical burdens associated with DRPs, strategies for preventing drug-related morbidity and mortality are urgently needed.
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Affiliation(s)
- F R Ernst
- College of Pharmacy, University of Arizona, Tucson 85721-0207, USA.
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35
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Hepler CD. Regulating for outcomes as a systems response to the problem of drug-related morbidity. JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION (WASHINGTON, D.C. : 1996) 2001; 41:108-15. [PMID: 11216101 DOI: 10.1016/s1086-5802(16)31211-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe the evidence that preventable adverse outcomes of drug therapy are prevalent in the United States and Europe, to describe the causes of this problem, to outline a systems response that would correct or improve the problem, to discuss pharmacy's contribution to that solution, and to propose a strategy for implementation. SUMMARY The causes of the widespread problem of preventable drug-related morbidity (PDRM) that have been identified in the literature constitute system failure. Health professionals can understand an individual patient's care system if they organize their thinking about systems as efficiently as they organize their thinking about medical or pharmaceutical problems. Six essential system characteristics are proposed, based on the PDRM literature. Regulations should mandate regular patient and system performance assessments--specifically, that health professionals (1) identify, resolve, and document specific pharmacotherapy problems; (2) assess system performance and identify recurring root causes of problems; and (3) document assessments, problems found, actions taken, and follow-up. These regulations would, in essence, mandate individual quality improvement (QI) programs. QI and pharmaceutical care require similar processes of decisions and actions, one from a practice (multipatient) perspective and the other from a patient perspective. CONCLUSION Health care accreditation agencies are moving toward regulation for outcomes. Pharmacy managers should embrace and regulatory boards should participate in this movement. Such regulations would clarify pharmacy's role in support of safe and effective pharmacotherapy and would constitute a commitment to pharmaceutical care as public service. A widely adopted system of measuring and improving the quality of medication use and outcomes could eventually lead to quality benchmarks in the community pharmacy setting, which would more firmly establish the value of the pharmacist in pharmacotherapy.
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Affiliation(s)
- C D Hepler
- DuBow Family Center for Research in Pharmaceutical Care, College of Pharmacy, University of Florida, Box 100496, Gainesville, FL 32610-0496, USA.
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Schattner A. Common pitfalls in case management. Lancet 1999; 353:1976. [PMID: 10371604 DOI: 10.1016/s0140-6736(05)77193-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Goettler M, Schneeweiss S, Hasford J. Adverse drug reaction monitoring—cost and benefit considerations. Part II: cost and preventability of adverse drug reactions leading to hospital admission. Pharmacoepidemiol Drug Saf 1998. [DOI: 10.1002/(sici)1099-1557(199710)6:3+3.0.co;2-o] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Major S, Badr S, Bahlawan L, Hassan G, Kojaoghlanian T, Khalil R, Melhem A, Richani R, Younes F, Yeretzian J, Khogali M, Sabra R. Drug-related hospitalization at a tertiary teaching center in Lebanon: incidence, associations, and relation to self-medicating behavior. Clin Pharmacol Ther 1998; 64:450-61. [PMID: 9797802 DOI: 10.1016/s0009-9236(98)90076-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In Lebanon there is very limited restriction on drug use. Accordingly, self-medication is highly prevalent. This study examined the influence of these factors on the development of drug-related illnesses that lead to hospitalization. METHODS Patients admitted to the medical and pediatric wards of a tertiary teaching center in Beirut, Lebanon, over a period of 6 months were interviewed and their charts were reviewed. Admissions attributable to adverse drug reactions or therapeutic failures were identified and characterized with respect to demographic factors, medical history, drug intake, and self-medicating behavior. The influence of these variables on the development of drug-related illnesses was examined by logistic regression. RESULTS Of 1745 adults and 457 children, there were 177 (10.2%) and 36 (7.9%) drug-related illnesses, respectively. Adverse drug reactions accounted for 7.0% and 5.7% and therapeutic failures for 3.2% and 2.2% of adult and pediatric admissions, respectively. Self-medication was commonly practiced (52.6% of adults and 41.6% of children). Logistic regression analysis revealed that female sex increased the risk of adverse drug reaction in adults, whereas self-medication decreased the risk. In children, the risk of adverse drug reaction was increased in lower socioeconomic groups, whereas the risk of therapeutic failure was increased by a positive history of atopy or drug reaction. CONCLUSIONS These results provide the first detailed analysis of the problem of drug-related illnesses in a developing country and identify a number of related or risk factors. Despite the lack of regulation of drug dispensing and the unchecked access to drugs in Lebanon, the incidence of drug-related illnesses is not different from that in Western nations. This finding may have relevance to policies of drug regulation in other countries.
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Affiliation(s)
- S Major
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, New York, NY 10022, USA
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Abstract
Neurologic illness relating to health care delivery has been increasingly described since the 1960's, primarily in the general medical literature. Iatrogenic neurologic complications have either been defined generically in terms of consequences of particular therapeutic or diagnostic approaches, or have been delineated with reference to more specific and serious complications such as intracerebral hemorrhage. In these reports, little attempt has been made to situate iatrogenic neurologic complications, either historically or conceptually, within the larger framework of medically related harms. Moreover, in this literature, few suggestions have been provided with regard to strategies to reduce such complications. The objective of the present review is to place the problem of iatrogenic neurologic complications within a larger historical and conceptual framework, as well as to provide suggestions for limiting such injuries.
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Affiliation(s)
- A I Faden
- Georgetown Institute for Cognitive and Computational Sciences and the Department of Neurology, Georgetown University Medical Center, Washington, DC 20007-2197, USA
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Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc 1998; 46:174-80. [PMID: 9475445 DOI: 10.1111/j.1532-5415.1998.tb02535.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the effect of a home-based intervention (HBI) on the frequency of unplanned readmission and out-of-hospital death among patients discharged home from acute hospital care. DESIGN A randomized controlled trial comparing HBI with usual care (UC). SETTING A tertiary referral hospital servicing the northwestern region of Adelaide, South Australia. PARTICIPANTS Medical and surgical patients (n = 762) discharged home after hospitalization. INTERVENTION Home-based intervention (n = 381) consisted of counseling of all patients before discharge followed by a single home visit (by a nurse and pharmacist) to those patients considered to be at high risk of readmission (n = 314) in order to optimize compliance with and knowledge of the treatment regimen, identify early clinical deterioration, and intensify follow-up of such patients where appropriate. MEASUREMENTS The primary endpoint was the number of unplanned readmissions plus out-of-hospital deaths over a 6-month follow-up period. RESULTS During the study follow-up, the major endpoint occurred most commonly in the UC group (217 vs 155 episodes: P < .001). Overall, the HBI group demonstrated fewer unplanned readmissions (154 vs 197: P = .022), out-of-hospital deaths (1 vs. 20: P < .001), total deaths (12 vs. 29: P = .006), emergency department attendances (236 vs 314: P < .001), and total days of hospitalization (1452 vs 1766: P < .001). There was a disproportionate reduction in multiple events among HBI patients (P = .035). Hospital-based costs of health care during study follow-up tended to be lower in the HBI group ($A2190 vs $A2680 per patient: P = .102). Mean cost of HBI was $A190 per patient visited, whereas other community-based health care costs were similar for both groups. CONCLUSIONS Among high-risk patients discharged from acute hospital care, HBI is beneficial in limiting unplanned readmissions and reducing risk of out-of-hospital death. It may be particularly cost-effective if applied selectively to patients with a history of frequent unplanned hospital admission.
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Affiliation(s)
- S Stewart
- Department of Cardiology, The Queen Elizabeth Hospital/University of Adelaide, Woodville, South Australia
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41
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Grainger-Rousseau TJ, Miralles MA, Hepler CD, Segal R, Doty RE, Ben-Joseph R. Therapeutic outcomes monitoring: application of pharmaceutical care guidelines to community pharmacy. JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION (WASHINGTON, D.C. : 1996) 1997; NS37:647-61. [PMID: 9425794 DOI: 10.1016/s1086-5802(16)30281-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To design a pharmaceutical care model, and develop and field test a set of community pharmacy guidelines and practice support materials--Therapeutic Outcomes Monitoring (TOM) modules. DESIGN Concept interviews with pharmacists, physicians, and patients; development and field testing of practice guidelines. SETTING Community pharmacies. PARTICIPANTS Five independent, five chain, and two clinic site pharmacies. INTERVENTIONS A prototype TOM module for asthma was developed through a seven-step process. Concept interviews were held with pharmacists, physicians, and patients to determine the desirability and feasibility of the TOM concept, prototype, and materials. Two field tests were completed and modifications made. Results were gathered through further concept interviews at the completion of the second field tests. MAIN OUTCOME MEASURES Participants' opinions and experiences. RESULTS Pharmacists, physicians, and patients expressed favorable attitudes about community pharmacists' participation in this pharmaceutical care model. Of the 12 participating pharmacists, 7 successfully implemented TOM in their practice sites and participated in the project throughout the testing; 49 patients were recruited into the study; and 22 patients remained in the program at the end of the second field test. In providing TOM services to these patients, the two most problematic areas for the pharmacists were in documenting care and reporting to physicians. A final phase of the TOM project has not been conducted in the United States because of insufficient numbers of patients for evaluating patient outcomes. CONCLUSION The TOM project was successful from a technical but not a marketing perspective. Useful practice guidelines can be written and taught to pharmacists. Enrollment of patients was difficult, and the concept is not likely to spread spontaneously within the existing market for pharmaceutical services.
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Abstract
Increasing age is often associated with multiple medical problems and therefore, the potential for increasing amounts of prescribed medication. Adverse reactions are a recognised hazard of drug therapy in elderly patients due to the amount of medication prescribed and the greater susceptibility of older people to adverse reactions. The problem is unlikely to diminish in the near future due to the proportionately increasing ageing population. Prevention of adverse drug reactions in the elderly deserves closer attention.
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Affiliation(s)
- G Cunningham
- School of Pharmacy, Robert Gordon University, Aberdeen
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43
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Abstract
Drug-treatment failures can be prevented by applying a Pharmaceutical Care system. Therapeutic outcome monitoring is such a system, which can be applied to the (drug) treatment of several diseases like asthma, diabetes and cardiovascular diseases. Pharmaceutical Care is an outcome oriented, cooperative, systematic approach to providing drug therapy directed at the improvement of all dimensions of health related quality of life.
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Affiliation(s)
- C D Hepler
- Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida Gainesville 32610-0496, USA
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44
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{BLR 2223} FDA - Labelling - Patient Information. Biotechnol Law Rep 1996. [DOI: 10.1089/blr.1996.15.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
OBJECTIVE To review and summarize studies reporting rates of drug-related hospital admissions. DATA SOURCES Manual and computerized literature searches using MEDLINE, Index Medicus, and International Pharmaceutical Abstracts as databases (key words: drug, drug-related, or iatrogenic; admission, hospital admission, or hospitalization; and ADR or adverse drug reaction). References from retrieved articles were searched to locate further studies. STUDY SELECTION Included were English-language studies of humans admitted to the hospital because of medications. Problems investigated were admissions prompted by adverse drug reactions (ADRs) when drugs were used by the patient and admissions resulting from a patient's noncompliant or unintentionally inappropriate drug use. Excluded were cases involving drug abuse, alcoholism, suicide attempts, intoxication, or inadequate prescribing. DATA SYNTHESIS Between 1966 and 1989, ADR rates from 49 hospitals or groups of hospitals in a variety of international settings were published in 36 articles. Samples sizes ranged from 41 to 11,891 patients, with a median of 714 (interquartile range [IQR] 275-1245) and a mean of 1412 (SD 2233). The prevalence of reported admissions resulting from ADRs ranged from 0.2 to 21.7 percent; the median was 4.9 percent (IQR 2.9-6.7 percent) and the mean was 5.5 percent (SD 4.1 percent). The weighted meta-analytic estimate was 5.1 percent (95 percent confidence interval 4.4-5.8). Of those ADR admissions, 71.5 percent were side effects, 16.8 percent excessive effects, 11.3 percent hypersensitivity reactions, and 0.4 percent idiosyncratic; 3.7 percent of patients admitted for ADRs died. Eleven reports indicated that 22.7 percent of ADR hospitalizations were induced by noncompliance. CONCLUSIONS Drug-induced hospitalizations account for approximately five percent of all admissions. Results apply only to people from highly developed industrialized countries. Economic analyses have not been performed. Future research should include the Third World and nonindustrialized nations as well as specific cultural groups.
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Affiliation(s)
- T R Einarson
- Faculty of Pharmacy, University of Toronto, Ontario, Canada
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Nichol MB, Michael LW. Critical analysis of the content and enforcement of mandatory consultation and patient profile laws. Ann Pharmacother 1992; 26:1149-55. [PMID: 1421685 DOI: 10.1177/106002809202600920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE This study evaluates the experience of 12 states that mandate that pharmacists provide consult services to patients and maintain drug profiles. DATA SOURCES An analysis of each state's statutes and regulations was complemented by telephone interviews of state licensing board staff. RESULTS Nine states specify the information to be provided during consultations, but only one (Florida) requires a comprehensive list of drug information, including adverse drug reactions, drug-drug interactions, directions for use, and necessary warnings. Eleven of the 12 states also require pharmacists to maintain patient drug profiles, but only 6 states specify the type of information to be included in profiles. State efforts to inform consumers about the pharmacist consultation requirement are limited, with only 7 states undertaking minimal promotional programs. The fact that no states reported any consumer consultation complaints or disciplinary actions against pharmacists for failure to consult illustrates the limited nature of mandatory consultation statues and regulations. CONCLUSIONS The wide variety of requirements demonstrates that these laws do not represent a uniform standard of practice. The lack of documented evidence regarding implementation invites questions regarding their usefulness and reinforces the need for enhanced monitoring activities.
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Affiliation(s)
- M B Nichol
- Department of Pharmaceutical Economics and Policy, School of Pharmacy, University of Southern California, Los Angeles 90033
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47
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Brooks JH, Renz KK, Richardson SL, White S, Hosey J. Systems versus performance problems: a peer review organization's perspective. QRB. QUALITY REVIEW BULLETIN 1992; 18:172-7. [PMID: 1298211 DOI: 10.1016/s0097-5990(16)30528-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
An analysis of Ohio's Medicare data base by the state's Peer Review Organization, using the most common diagnosis-related group in the Medicare population (heart failure and shock), from January 1, 1989 to January 1, 1991, identified 72 cases with confirmed quality-of-care problems. The analysis was performed to determine whether the majority of quality-of-care problems are related to systems or performance deficiencies. Study results indicated that health care workers are being inappropriately blamed for problems that are inherent in the health care system--74% of problems were related to inefficiencies in the health care delivery system, and 26% were determined to reflect performance problems.
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Affiliation(s)
- J H Brooks
- Peer Review Systems, Inc, Columbus, Ohio 43231-7900
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48
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49
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Fincham JE. An overview of adverse drug reactions. AMERICAN PHARMACY 1991; NS31:47-52. [PMID: 1858661 DOI: 10.1016/s0160-3450(16)33754-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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50
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Affiliation(s)
- C D Hepler
- Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, Gainesville 32610
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