Chihiro Noguchi1, Mio Sakuma1, Yoshinori Ohta2, David W Bates3,4, Takeshi Morimoto5. 1. Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan. 2. Division of General Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan. 3. Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. 4. Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA. 5. Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan. tm@hyo-med.ac.jp.
Abstract
INTRODUCTION: The nature of medication errors (MEs) and the frequency of identified or intercepted MEs are not being scrutinized in daily practice in Japan. OBJECTIVES: The aim of this study was to clarify the epidemiology of MEs and the risk factors for non-intercepted and unidentified MEs. METHODS: The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive patients (N = 3459) aged ≥15 years who were admitted to the study wards. MEs were identified by on-site reviews of all medical charts, self-reports, and prescription queries by pharmacists. Two independent physicians reviewed and classified all MEs and adverse drug events and determined the stages at which the MEs occurred and whether there was interception or identification of the MEs. RESULTS: A total of 514 MEs were observed among 433 patients. Sixty-four percent of MEs occurred at the ordering stage. Among these, 60 % were due to duplicate drug orders. Overall, 63 % and 45 % of MEs were not intercepted or identified during hospitalization, respectively. The independent risk factors for non-intercepted MEs were hospitalization in the surgical ward (odds ratio [OR] 2.94) and the intensive care unit (OR 3.57). MEs by resident physicians were more likely to be intercepted (OR 0.52 for non-intercepted MEs). CONCLUSIONS: MEs frequently occurred and most at the ordering stage. Almost half of MEs were not intercepted or identified. Many MEs at the later stages were less likely to be intercepted and resulted in actual patient harm. Systems to improve the identification and interception of MEs should be implemented.
INTRODUCTION: The nature of medication errors (MEs) and the frequency of identified or intercepted MEs are not being scrutinized in daily practice in Japan. OBJECTIVES: The aim of this study was to clarify the epidemiology of MEs and the risk factors for non-intercepted and unidentified MEs. METHODS: The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive patients (N = 3459) aged ≥15 years who were admitted to the study wards. MEs were identified by on-site reviews of all medical charts, self-reports, and prescription queries by pharmacists. Two independent physicians reviewed and classified all MEs and adverse drug events and determined the stages at which the MEs occurred and whether there was interception or identification of the MEs. RESULTS: A total of 514 MEs were observed among 433 patients. Sixty-four percent of MEs occurred at the ordering stage. Among these, 60 % were due to duplicate drug orders. Overall, 63 % and 45 % of MEs were not intercepted or identified during hospitalization, respectively. The independent risk factors for non-intercepted MEs were hospitalization in the surgical ward (odds ratio [OR] 2.94) and the intensive care unit (OR 3.57). MEs by resident physicians were more likely to be intercepted (OR 0.52 for non-intercepted MEs). CONCLUSIONS: MEs frequently occurred and most at the ordering stage. Almost half of MEs were not intercepted or identified. Many MEs at the later stages were less likely to be intercepted and resulted in actual patient harm. Systems to improve the identification and interception of MEs should be implemented.
Authors: Eric G Poon; Carol A Keohane; Catherine S Yoon; Matthew Ditmore; Anne Bane; Osnat Levtzion-Korach; Thomas Moniz; Jeffrey M Rothschild; Allen B Kachalia; Judy Hayes; William W Churchill; Stuart Lipsitz; Anthony D Whittemore; David W Bates; Tejal K Gandhi Journal: N Engl J Med Date: 2010-05-06 Impact factor: 91.245
Authors: D W Bates; J M Teich; J Lee; D Seger; G J Kuperman; N Ma'Luf; D Boyle; L Leape Journal: J Am Med Inform Assoc Date: 1999 Jul-Aug Impact factor: 4.497
Authors: Ahmad P Tafti; Jonathan Badger; Eric LaRose; Ehsan Shirzadi; Andrea Mahnke; John Mayer; Zhan Ye; David Page; Peggy Peissig Journal: JMIR Med Inform Date: 2017-12-08
Authors: Alain K Koyama; Claire-Sophie Sheridan Maddox; Ling Li; Tracey Bucknall; Johanna I Westbrook Journal: BMJ Qual Saf Date: 2019-08-07 Impact factor: 7.035
Authors: Fouzia Lghoul-Oulad Saïd; Karin Hek; Linda E Flinterman; Ron Mc Herings; Margaretha F Warlé-van Herwaarden; Sandra de Bie; Vera E Valkhoff; Jelmer Alsma; Mees Mosseveld; Ann M Vanrolleghem; Bruno Hch Stricker; Miriam Cjm Sturkenboom; Peter Agm De Smet; Patricia Mla van den Bemt Journal: Pharmacoepidemiol Drug Saf Date: 2020-10-13 Impact factor: 2.890