Medication-related Events Research Articles

A Few Simple Steps Can Avert Medical Errors

A Few Simple Steps Can Avert Medical Errors

Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital.

A prospective and retrospective case analysis study of all perioperative cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia. One hundred forty-four cases of cardiac arrest within 24 h of surgery were identified over a 10-yr period from an anesthesia database of 72,959 anesthetics. Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were anesthesia-contributory. The rates of anesthesia-attributable and anesthesia-contributory cardiac arrest were estimated. Fifteen cardiac arrests out of a total number of 144 were judged to be related to anesthesia. Five cardiac arrests were anesthesia-attributable, resulting in an anesthesia-attributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085-1.29). Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52-2.22). Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction. The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011-1.09). Most perioperative cardiac arrests were related to medication administration, airway management, and technical problems of central venous access. Improvements focused on these three areas may result in better outcomes.

Unplanned Medication‐Related Admissions to an Acute Care General Teaching Hospital

To determine the incidence and preventability of unplanned admissions to a State acute care general teaching hospital caused by adverse medication‐related events (AMREs).

The epidemiology of adverse and unexpected events in the long-term care setting.

To describe the adverse and unexpected events reported by staff over a 1-year period in a large, long-term care institution. A retrospective review of resident incident reports. A 703-bed, academically oriented, long-term care facility. Residents of the facility have a mean age of 88.5 years, are 76% female, and have an average length of stay of 4.3 years. Of the 3,390 adverse and unexpected events reports over the 1-year study period, falls (with and without associated injury) were the most frequently reported incidents, followed by non-fall-related injuries, medication-related events, and wandering episodes. While a large proportion of falls occurred in ambulating residents (47%), the majority occurred under different circumstances including falls from bed, wheelchair, and commode/toilet. Bruises and skin tears were the most frequently reported fall- and non-fall-related injuries. The annual incidence rates for falls, fall-related injuries, and non-fall-related injuries varied according to resident care unit level, with semi-dependent residents experiencing the highest rates of falls and dependent residents experiencing the highest rates of non-fall-related injuries. Circadian patterns in the incidence of these events varied according to resident care level. Information regarding adverse and unexpected events in the long-term care setting can be organized into databases that allow analysis of patterns and trends. The results of these analyses may be helpful in targeting limited resources to areas of greatest need within an individual institution and for comparing quality of care across different long-term care facilities.

Use of a computer to detect and respond to clinical events: its effect on clinician behavior.

A computer was used to prospectively detect and suggest responses to simple, medication-related events as reflected in a computerized record in a prospective, randomized study of a diabetes clinic with primary-care responsibility. There were two categories of event/suggestions: when the last observation of a test required for medication control was too old, the computer suggested a repeat; and when an abnormality with therapeutic implications was detected, the computer suggested a specific change in therapeutics. Clinicians responded to 36% of events in the first category with computer reminders and 11% without (P less than 0.0001); they responded to 28% of events in the second category with computer assistance and 13% without (P less than 0.026). For the most clinically significant of these second category events, the difference was even greater: 47% with and 4% without computer assistance (P less than 0.0004). I believe that computer detection and response (in the form of reminders) to simple clinical events will change clinician behavior.