Using Information Technology to Screen for Adverse Events
Using Information Technology to Screen for Adverse Events
The issue of medication safety came into the public's consciousness with publication of two key Institute of Medicine reports. The first suggested that medical errors kill thousands of people per year -- more than from suicides, highway accidents, breast cancer, or AIDS. The second report was intended to be a blueprint for how health care practitioners need to change the care they provide so that it is safe, effective, patient centered, timely, efficient, and equitable. To achieve these goals, providers need to use more information technology in health care.
In addressing medication safety, it is important to understand the relationship among medication errors, potential adverse drug events (ADEs), and preventable ADEs. Medication errors are very common, with most having relatively little potential for harm. However, a small proportion have that potential. Health care practitioners are most interested in the preventable ADEs (although most ADEs are not preventable). Bates et al. reported that, for 10,070 drug orders administered, there were 530 medication errors (1.4 errors per admission), 35 potential ADEs, and 5 preventable ADEs. One in 100 medication errors caused an ADE, and 7 in 100 had the potential to do so. Extrapolating these numbers to a 700-bed hospital yields a conservative estimate of approximately 300,000 medication errors, 1,900 ADEs (530 preventable ADEs plus 1,370 nonpreventable ADEs), and 1,600 potential ADEs per year. Although the number of medication errors is unacceptably high, many administrators are not aware of the problem according to an unpublished survey by Bruskin-Goldring. Safety needs to be viewed as a top priority by the health care community, particularly its leadership.
The issue of medication safety came into the public's consciousness with publication of two key Institute of Medicine reports. The first suggested that medical errors kill thousands of people per year -- more than from suicides, highway accidents, breast cancer, or AIDS. The second report was intended to be a blueprint for how health care practitioners need to change the care they provide so that it is safe, effective, patient centered, timely, efficient, and equitable. To achieve these goals, providers need to use more information technology in health care.
In addressing medication safety, it is important to understand the relationship among medication errors, potential adverse drug events (ADEs), and preventable ADEs. Medication errors are very common, with most having relatively little potential for harm. However, a small proportion have that potential. Health care practitioners are most interested in the preventable ADEs (although most ADEs are not preventable). Bates et al. reported that, for 10,070 drug orders administered, there were 530 medication errors (1.4 errors per admission), 35 potential ADEs, and 5 preventable ADEs. One in 100 medication errors caused an ADE, and 7 in 100 had the potential to do so. Extrapolating these numbers to a 700-bed hospital yields a conservative estimate of approximately 300,000 medication errors, 1,900 ADEs (530 preventable ADEs plus 1,370 nonpreventable ADEs), and 1,600 potential ADEs per year. Although the number of medication errors is unacceptably high, many administrators are not aware of the problem according to an unpublished survey by Bruskin-Goldring. Safety needs to be viewed as a top priority by the health care community, particularly its leadership.
