Adverse Events in Community Hospitals Involving Nephrotoxic Drugs
Adverse Events in Community Hospitals Involving Nephrotoxic Drugs
Medication errors in patients with reduced creatinine clearance are harmful and costly; however, most studies have been conducted in large academic hospitals. As there are few studies regarding this issue in smaller community hospitals, we conducted a multicenter, retrospective cohort study in six community hospitals (100 to 300 beds) to assess the incidence and severity of adverse drug events (ADEs) in patients with reduced creatinine clearance. A chart review was performed on adult patients hospitalized during a 20-month study period with serum creatinine over 1.5mg/dl who were exposed to drugs that are nephrotoxic or cleared by the kidney. Among 109,641 patients, 17,614 had reduced creatinine clearance, and in a random sample of 900 of these patients, there were 498 potential ADEs and 90 ADEs. Among these ADEs, 91% were preventable, 51% were serious, 44% were significant, and 4.5% were life threatening. Of the potential ADEs, 54% were serious, 44% were significant, 1.6% were life threatening, and 96.6% were not intercepted. All 82 preventable events could have been intercepted by renal dose checking. Our study shows that ADEs were common in patients with impaired kidney function in community hospitals, and many appear potentially preventable with renal dose checking.
Medication errors are common in hospitals. Between 44,000 and 98,000 Americans die each year because of medical errors and about 1 million people are injured. The leading cause of medical injury in hospitalized patients in the Harvard Medical Practice Study was the use of drugs, accounting for 19.4% of injuries.
Reduced creatinine clearance is not uncommon in hospitalized patients, and it has important consequences. One review found a rate of 1% on hospital admission, 2–5% during hospitalization, and even higher rates of 4–15% in patients with certain surgical procedures such as cardiopulmonary bypass surgery. A 12-month study controlling for alerts with computerized physician order entry (CPOE) in place found 12% of alerts being associated with renal insufficiency or electrolyte imbalance. Furthermore, reduced creatinine clearance is associated with a 5.5 times higher risk of dying than in patients without reduced creatinine clearance.
Adverse drug events (ADEs) can prolong the length of stay (LOS) and increase costs in patients with reduced creatinine clearance. A study found a mean adjusted increased LOS of 8.2 days and adjusted additional costs of $29,823 in patients with acute renal insufficiency because of amphotericin B therapy. It has been shown that clinical decision support systems can reduce the prolonged LOS in patients with reduced creatinine clearance. In a study including 97,151 medication orders in patients with reduced creatinine clearance, guided medication dosing with clinical decision support systems improved the appropriateness of dose by 13% and appropriateness of frequency by 24%. Furthermore, a randomized, cross-sectional trial in a university hospital intensive care unit-setting in Belgium showed a threefold reduction of medication prescription errors comparing patients with renal insufficiency in a setting with CPOE combined with clinical decision support system with a paper-based setting.
These and other advantages of CPOE systems in improving care led to the formation of the Massachusetts Hospital CPOE Initiative, which was launched in 2005, with supporting legislation passed in spring 2006. Coordinated by the Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute in collaboration with the Massachusetts Hospital Association and the Massachusetts Council of Community Hospitals, the initiative has the goal of implementing CPOE in all community hospitals across the state within 4 years.
Relatively few data are available from community hospitals on the frequency of renal insufficiency and the use of nephrotoxic and renally excreted drugs. We therefore assessed the baseline rate of renally impaired patients and their ADE rates in six community hospitals before the introduction of CPOE systems.
Abstract and Introduction
Abstract
Medication errors in patients with reduced creatinine clearance are harmful and costly; however, most studies have been conducted in large academic hospitals. As there are few studies regarding this issue in smaller community hospitals, we conducted a multicenter, retrospective cohort study in six community hospitals (100 to 300 beds) to assess the incidence and severity of adverse drug events (ADEs) in patients with reduced creatinine clearance. A chart review was performed on adult patients hospitalized during a 20-month study period with serum creatinine over 1.5mg/dl who were exposed to drugs that are nephrotoxic or cleared by the kidney. Among 109,641 patients, 17,614 had reduced creatinine clearance, and in a random sample of 900 of these patients, there were 498 potential ADEs and 90 ADEs. Among these ADEs, 91% were preventable, 51% were serious, 44% were significant, and 4.5% were life threatening. Of the potential ADEs, 54% were serious, 44% were significant, 1.6% were life threatening, and 96.6% were not intercepted. All 82 preventable events could have been intercepted by renal dose checking. Our study shows that ADEs were common in patients with impaired kidney function in community hospitals, and many appear potentially preventable with renal dose checking.
Introduction
Medication errors are common in hospitals. Between 44,000 and 98,000 Americans die each year because of medical errors and about 1 million people are injured. The leading cause of medical injury in hospitalized patients in the Harvard Medical Practice Study was the use of drugs, accounting for 19.4% of injuries.
Reduced creatinine clearance is not uncommon in hospitalized patients, and it has important consequences. One review found a rate of 1% on hospital admission, 2–5% during hospitalization, and even higher rates of 4–15% in patients with certain surgical procedures such as cardiopulmonary bypass surgery. A 12-month study controlling for alerts with computerized physician order entry (CPOE) in place found 12% of alerts being associated with renal insufficiency or electrolyte imbalance. Furthermore, reduced creatinine clearance is associated with a 5.5 times higher risk of dying than in patients without reduced creatinine clearance.
Adverse drug events (ADEs) can prolong the length of stay (LOS) and increase costs in patients with reduced creatinine clearance. A study found a mean adjusted increased LOS of 8.2 days and adjusted additional costs of $29,823 in patients with acute renal insufficiency because of amphotericin B therapy. It has been shown that clinical decision support systems can reduce the prolonged LOS in patients with reduced creatinine clearance. In a study including 97,151 medication orders in patients with reduced creatinine clearance, guided medication dosing with clinical decision support systems improved the appropriateness of dose by 13% and appropriateness of frequency by 24%. Furthermore, a randomized, cross-sectional trial in a university hospital intensive care unit-setting in Belgium showed a threefold reduction of medication prescription errors comparing patients with renal insufficiency in a setting with CPOE combined with clinical decision support system with a paper-based setting.
These and other advantages of CPOE systems in improving care led to the formation of the Massachusetts Hospital CPOE Initiative, which was launched in 2005, with supporting legislation passed in spring 2006. Coordinated by the Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute in collaboration with the Massachusetts Hospital Association and the Massachusetts Council of Community Hospitals, the initiative has the goal of implementing CPOE in all community hospitals across the state within 4 years.
Relatively few data are available from community hospitals on the frequency of renal insufficiency and the use of nephrotoxic and renally excreted drugs. We therefore assessed the baseline rate of renally impaired patients and their ADE rates in six community hospitals before the introduction of CPOE systems.