Preventing adverse drug events in hospital practice: An overview

Pharmacoepidemiology and Drug Safety

Volumn 16, Issue 10, 2007, Pages 1129-1135

  Rommers, Mirjam K ^a   Teepe Twiss, Irene M ^a   Guchelaar, Henk Jan ^a  

^a LEIDEN UNIVERSITY MEDICAL CENTER   (Netherlands)

Author keywords

Adverse drug events; Clinical decision support systems; Computerised physician order entry; Hospital practice; Medication safety

Indexed keywords

CLINICAL DECISION MAKING; CLINICAL LABORATORY; CLINICAL PHARMACY; DECISION SUPPORT SYSTEM; DISEASE SEVERITY; DRUG MONITORING; DRUG SAFETY; DRUG USE; ELECTRONIC MEDICAL RECORD; HOSPITAL CARE; HOSPITAL INFORMATION SYSTEM; HOSPITAL PHARMACY; HUMAN; INCIDENCE; MORBIDITY; MORTALITY; PHARMACIST; PRIORITY JOURNAL; REVIEW;

DECISION SUPPORT SYSTEMS, CLINICAL; DRUG MONITORING; DRUG THERAPY, COMPUTER-ASSISTED; HUMANS; MEDICATION SYSTEMS, HOSPITAL; PHARMACEUTICAL PREPARATIONS;

EID: 35649006857     PISSN: 10538569     EISSN: 10991557     Source Type: Journal    
DOI: 10.1002/pds.1440     Document Type: Review

References (63)

1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377-384.
2. Al Tajir GK, Kelly WN. Epidemiology, comparative methods of detection, and preventability of adverse drug events. Ann Pharmacother 2005; 39:1169-1174.
3. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drag events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29-34.
4. Blix HS, Viktil KK, Reikvam A, et al. The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals. Eur J Clin Pharmacol 2004; 60: 651-668.
5. Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991; 266:2847-2851.
6. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997; 277: 301-306.
7. Forster A J, Halil RB, Tierney MG. Pharmacist surveillance of adverse drug events. Am J Health Syst Pharm 2004; 61: 1466-1472.
8. Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003; 60: 1750-1759.
9. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-2120.
10. Kelly WN. Potential risks and prevention, Part 4: Reports of significant adverse drug events. Am J Health Syst Pharm 2001; 58: 1406-1412.
11. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: 1200-1205.
12. Nebeker JR, Hoffman JM, Weir CR, et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 2005; 165: 1111-1116.
13. von Lane NC, Schwappach DL, Koeck CM. The epidemiology of preventable adverse drug events: a review of the literature. Wien Klin Wochenschr 2003; 115: 407-415.
14. World Health Organisation. Safety Monitoring of Medicianl Products: guidelines for setting up and running a pharmacovigilance centre (UMC) [online]. Available from URL: http://www.who.int/medicines/areas/ quality_safety/safety_efficacy/en/index.html [Accessed 2006 Jul 4].
15. Leape LL. Preventing adverse drug events. Am J Health Syst Pharm 1995; 52: 379-382.
16. Morimoto T, Gandhi TK, Seger AC, et al. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13: 306-314.
17. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors [online]. Available from URL: http://www.nccmerp.org/[Accessed 2006 Jul 4].
18. Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79: 718-722.
19. Honigman B, Lee J, Rothschild J, et al. Using computerized data to identify adverse drug events in outpatients. J Am Med Inform Assoc 2001; 8: 254-266.
20. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet 2000; 356: 1255-1259.
21. Kramer MS, Leventhal JM, Hutchinson TA, et al. An algorithm for the operational assessment of adverse drug reactions. I. Background, description, and instructions for use. JAMA 1979; 242: 623-632.
22. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239-245.
23. Bates DW, Evans RS, Murff H, et al. Detecting adverse events using information technology. J Am Med Inform Assoc 2003; 10: 115-128.
24. Field TS, Gurwitz JH, Harrold LR, et al. Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc 2004; 11: 492-498.
25. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998; 5: 305-314.
26. Murff HJ, Forster AJ, Peterson JF, et al. Electronically screening discharge summaries for adverse medical events. J Am Med Inform Assoc 2003; 10: 339-350.
27. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997; 277:307-31 I.
28. White TJ, Arakelian A, Rho JP. Counting the costs of drug-related adverse events. Pharmacoeconomics 1999; 15: 445-458.
29. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274: 35-43.
30. Bates DW, Miller EB, Cullen DJ, et al. Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group. Arch Intern Med 1999; 159: 2553-2560.
31. Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a community hospital. Qual Saf Health Care 2005; 14: 169-174.
32. Leonard MS, Cimino M, Shaha S, et al. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Pediatrics 2006; 118: e1124-e1129.
33. Guchelaar HJ, Colen HB, Kalmeijer MD, et al. Medication errors: hospital pharmacist perspective. Drugs 2005; 65: 1735-1746.
34. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003; 111: 722-729.
35. Evans RS, Lloyd JF, Stoddard GJ, et al. Risk factors for adverse drug events: a 10-year analysis. Ann Pharmacother 2005; 39:1161-1168.
36. Silverman JB, Stapinski CD, Churchill WW, et al. Multifaceted approach to reducing preventable adverse drug events. Am J Health Syst Pharm 2003; 60: 582-586.
37. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282: 267-270.
38. Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003; 163: 2014-2018.
39. Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006; 166: 955-964.
40. Wang JK, Herzog NS, Kaushal R, et al. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics 2007; 119: e77-e85.
41. Guchelaar H J, Kalmeijer MD. The potential role of computerisation and information technology in improving prescribing in hospitals. Pharm World Sci 2003; 25: 83-87.
42. Kalmeijer MD, Holtzer W, van Dongen R, et al. Implementation of a computerized physician medication order entry system at the Academic Medical Centre in Amsterdam. Pharm World Sci 2003; 25: 88-93.
43. The Leapfrog Group. The Leapfrog safety practices in hospitals [online]. Available from URL: http://www.leapfroggroup.org/ [Accessed 2006 Jul 4].
44. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163: 1409-1416.
45. Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 2007; 14: 29-40.
46. Osheroff JA, Teich JM, Middleton B, et al. A roadmap for national action on clinical decision support. J Am Med Inform Assoc 2007; 14: 141-145.
47. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280: 1311-1316.
48. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6: 313-321.
49. Colpaert K, Claus B, Somers A, et al. Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. Crit Care 2006; 10: R21.
50. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005; 116: 1506-1512.
51. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293: 1197-1203.
52. Bates DW. Computerized physician order entry and medication errors: finding a balance. J Biomed Inform 2005; 38: 259-261.
53. Murff HJ, Patel VL, Hripcsak G, et al. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform 2003; 36: 131-143.
54. Raschke RA, Gollihare B, Wunderlich TA, et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital. JAMA 1998; 280: 1317-1320.
55. Silverman JB, Stapinski CD, Huber C, et al. Computer-based system for preventing adverse drug events. Am J Health Syst Pharm 2004; 61: 1599-1603.
56. van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138-147.
57. Schiff GD, Klass D, Peterson J, et al. Linking laboratory and pharmacy: opportunities for reducing errors and improving care. Arch Intern Med 2003; 163: 893-900.
58. Goldberg DE, Baardsgaard G, Johnson MT, et al. Computer-based program for identifying medication orders requiring dosage modification based on renal function. Am J Hosp Pharm 1991; 48: 1965-1969.
59. Peterson JP, Colucci VJ, Schiff SE. Using serum creatinine concentrations to screen for inappropriate dosage of renally eliminated drugs. Am J Hosp Pharm 1991; 48: 1962-1964.
60. Schiff GD, Aggarwal HC, Kumar S, et al. Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems. Am J Med 2000; 109: 494-497.
61. Raebel MA, Lyons EE, Chester EA, et al. Improving laboratory monitoring at initiation of drug therapy in ambulatory care: a randomized trial. Arch Intern Med 2005; 165: 2395-2401.
62. Kane-Gill SL, Dasta JF, Schneider PJ, et al. Monitoring abnormal laboratory values as antecedents to drug-induced injury. J Trauma 2005; 59: 1457-1462.
63. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348: 2526-2534.