Adverse Drug Event Occurences

I’ve been working with a group here on a Failure Mode and Effects Analysis (FMEA)  for our bar coding medication administration project (called MAK –Medication Administration checKing by our vendor, Siemens Medical ). The benefit to implementing such as system is to significantly reduce the number of errors that occur during medication administration in hospitals each year.

While researching the project I have come across several interesting facts. I would like to share them with you here.

A study by Bates in The Journal of the American Medical Association(1) reported the following results from their experiences with adverse drug events (ADEs):

1%  were fatal (none preventable),
12% were life-threatening,
30% were serious
57% were significant.

Of those ADEs above:
28% were judged preventable.
42% of the life-threatening and serious ADEs were preventable
18% of the significant ADEs were preventable

Of the preventable ADEs:
56% occurred during ordering (i.e. provider’s written order)
34% occurred during administration
6% occurred during transcription
4% occurred during dispensing (i.e. pharmacy)

48% of the ADEs that occurred during the ordering process were caught versus 0% at the administration stage. And that my friends is the key to implementing a bar coding medication administration system. Zero percent of the errors that occur during administration were caught. That is 100% failure.

In regards to why to error occurred(2):

The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of errors.

Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors.

Seven systems failures accounted for 78% of the errors

(1) Bates DW, Cullen DJ, Laird N et al.  Incidence of adverse drug events and potential adverse drug events-implications for prevention.  JAMA.  1995;274:29-34).

(2) Leape LL, Bates DW, Cullen KJ et al.  Systems analysis of adverse drug events.  JAMA.  1995;274:35-43

5 thoughts on “Adverse Drug Event Occurences”

  1. Your articles are from 1995 – isn’t that before most facilities had unit dose dispensing cabinets (or whatever pxyis’ are called)…..

    It is a great post Jerry but would like to see more recent data.


  2. You are correct, Laura. This information is a little dated, but is the benchmark data for which we compare all current systems. Automated dispensing cabinets -ADUs- like Pyxis and Omnicell have been around for quite some time, but are currently being used in conjunction with newer technologies to improve patient safety.

    The administration phase of medication is the last, best hope we have for catching a mistake before it reaches the patient, and that is where bedside barcoded medication administration will make it’s biggest impact.

    Perhaps advances in technologies to improve medication safety will lead to newer studies. Until then, this is what we have to work with.

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