Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools

• Published in: American journal of health-system pharmacy 2012-02, Vol.69 (3), p.221-227
• Main Authors: Wright, Adam, Feblowitz, Joshua, Phansalkar, Shobha, Liu, Jialin, Wilcox, Allison, Keohane, Carol A, Seger, Diane L, Bloomrosen, Meryl, Kuperman, Gilad J, Bates, David W
• Format: Article
• Language: English
• Subjects: Adverse and side effects; Cohort Studies; Decision support systems; Decision Support Systems, Clinical; Drug Interactions; Drug Overdose; Drug-Related Side Effects and Adverse Reactions; Drugs; Hospitals, Community; Humans; Massachusetts; Medication errors; Medication Errors - prevention & control; Pharmaceutical Preparations - administration & dosage; Polypharmacy; Prevention; Retrospective Studies; Safety and security measures
• ISSN: 1079-2082; 1535-2900
• DOI: 10.2146/ajhp110084

The results of a retrospective evaluation of the frequency and preventability of adverse drug events (ADEs) involving multiple drugs among hospital inpatients are reported. Data collected in a previous cohort study of 180 actual ADEs and 552 potential ADEs (PADEs) at six community hospitals in Massachusetts were analyzed to determine the frequency and types of multiple-drug ADEs and the extent to which the ADEs might have been prevented using publicly available clinical decision-support (CDS) knowledge bases. None of the hospitals had a computerized prescriber-order-entry system at the time of data collection (January 2005-August 2006). A total of 17 ADEs (rate, 1.4 per 100 admissions) and 146 PADEs (rate, 12.2 per 100 admissions) involving multiple drugs were identified. The documented events were related to drug duplication (n = 126), drug-drug interaction (n = 21), additive effects (n = 14), and therapeutic duplication (n = 7) or a combination of those factors. The majority of actual ADEs were due to drug-drug interactions, most commonly involving opioids, benzodiazepines, or cardiac medications; about 75% of the PADEs involved excessive drug doses resulting from order duplication or the prescribing of combination drugs with overlapping ingredients, usually products containing acetaminophen and an opioid. It was determined that 5 (29.4%) of the ADEs and 131 (89.7%) of the PADEs could have been detected through the use of the evaluated CDS tools. A substantial number of actual ADEs and PADEs in the community hospital setting may be preventable through the use of publicly available CDS knowledge bases.