Defining and classifying terminology for medication harm: a call for consensus

Evaluating EHR-Integrated Digital Technologies for Medication-Related Outcomes and Health Equity in Hospitalised Adults: A Scoping Review

The purpose of this scoping review is to identify and evaluate studies that examine the effectiveness and implementation strategies of Electronic Health Record (EHR)-integrated digital technologies aimed at improving medication-related outcomes and promoting health equity among hospitalised adults. Using the Consolidated Framework for Implementation Research (CFIR), the implementation methods and outcomes of the studies were evaluated, as was the assessment of methodological quality and risk of bias. Searches through Medline, Embase, Web of Science, and CINAHL Plus yielded 23 relevant studies from 1,232 abstracts, spanning 11 countries and from 2008 to 2022, with varied research designs. Integrated digital tools such as alert systems, clinical decision support systems, predictive analytics, risk assessment, and real-time screening and surveillance within EHRs demonstrated potential in reducing medication errors, adverse events, and inappropriate medication use, particularly in older patients. Challenges include alert fatigue, clinician acceptance, workflow integration, cost, data integrity, interoperability, and the potential for algorithmic bias, with a call for long-term and ongoing monitoring of patient safety and health equity outcomes. This review, guided by the CFIR framework, highlights the importance of designing health technology based on evidence and user-centred practices. Quality assessments identified eligibility and representativeness issues that affected the reliability and generalisability of the findings. This review also highlights a critical research gap on whether EHR-integrated digital tools can address or worsen health inequities among hospitalised patients. Recognising the growing role of Artificial Intelligence (AI) and Machine Learning (ML), this review calls for further research on its influence on medication management and health equity through integration of EHR and digital technology.

Medication errors in veterinary anesthesia: a literature review

OBJECTIVE

To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction.

DATABASES USED

PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗].

CONCLUSIONS

Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction

INTRODUCTION

The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI.

METHODS

This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted.

RESULTS

A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days).

CONCLUSION

Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

International Trends in Adverse Drug Event-Related Mortality from 2001 to 2019: An Analysis of the World Health Organization Mortality Database from 54 Countries

BACKGROUND AND OBJECTIVE

Adverse drug events (ADEs) are becoming a significant public health issue. However, reports on ADE-related mortality are limited to national-level evaluations. Therefore, we aimed to reveal overall trends in ADE-related mortality across the 21st century on an international level.

METHODS

This observational study analysed long-term trends in ADE-related mortality rates from 2001 to 2019 using the World Health Organization Mortality Database. The rates were analysed according to sex, age and region. North America, Latin America and the Caribbean, Western Europe, Eastern Europe and Western Pacific regions were assessed. Fifty-four countries were included with four-character International Statistical Classification of Disease and Related Health Problems, Tenth Revision codes in the database, population data in the World Population Prospects 2019 report, mortality data in more than half of the study period, and high-quality or medium-quality death registration data. A locally weighted regression curve was used to show international trends in age-standardised rates.

RESULTS

The global ADE-related mortality rate per 100,000 population increased from 2.05 (95% confidence interval 0.92-3.18) in 2001 to 6.86 (95% confidence interval 5.76-7.95) in 2019. Mortality rates were higher among men than among women, especially in those aged 20-50 years. The population aged ≥ 75 years had higher ADE-related mortality rates than the younger population. North America had the highest mortality rate among the five regions. The global ADE-related mortality rate increased by approximately 3.3-fold from 2001 to 2019.

CONCLUSIONS

The burden of ADEs has increased internationally with rising mortality rates. Establishing pharmacovigilance systems can facilitate efforts to reduce ADE-related mortality rates globally.

Parents' understanding of medication at discharge and potential harm in children with medical complexity

OBJECTIVE

Children with medical complexity (CMC) are among the most vulnerable patient groups. This study aimed to evaluate their prevalence and risk factors for medication misunderstanding and potential harm (PH) at discharge.

DESIGN AND SETTING

Cross-sectional study at a tertiary care centre.

STUDY POPULATION

CMC admitted at Medical University of Vienna between May 2018 and January 2019.

INTERVENTION

CMC and caregivers underwent a structured interview at discharge; medication understanding and PH for adverse events were assessed by a hybrid approach.

MAIN OUTCOME MEASURES

Medication misunderstanding rate; PH.

RESULTS

For 106 included children (median age 9.6 years), a median number of 5.0 (IQR 3.0-8.0) different medications were prescribed. 83 CMC (78.3%) demonstrated at least one misunderstanding, in 33 CMC (31.1%), potential harm was detected, 5 of them severe. Misunderstandings were associated with more medications (r=0.24, p=0.013), new prescriptions (r=0.23, p=0.019), quality of medication-related communication (r=-0.21, p=0.032), low level of education (p=0.013), low language skills (p=0.002) and migratory background (p=0.001). Relative risk of PH was 2.27 times increased (95% CI 1.23 to 4.22) with new medications, 2.14 times increased (95% CI 1.10 to 4.17) with migratory background.

CONCLUSION

Despite continuous care at a tertiary care centre and high level of subjective satisfaction, high prevalence of medication misunderstanding with relevant risk for PH was discovered in CMC and their caregivers. This demonstrates the need of interventions to improve patient safety, with stratification of medication-related communication for high-risk groups and a restructured discharge process focusing on detection of misunderstandings ('unknown unknowns').

Adverse drug reactions in hospitals: population estimates for Portugal and the ICD-9-CM to ICD-10-CM crosswalk

BACKGROUND

Adverse drug reactions (ADR), both preventable and non-preventable, are frequent and pose a significant burden. This study aimed to produce up-to-date estimates for ADR rates in hospitals, in Portugal, from 2010 to 2018. In addition, it explores possible pitfalls when crosswalking between ICD-9-CM and ICD-10-CM code sets for ADR identification.

METHODS

The Portuguese Hospital Morbidity Database was used to identify hospital episodes (outpatient or inpatient) with at least one ICD code of ADR. Since the study period spanned from 2010 to 2018, both ICD-9-CM and ICD-10-CM codes based on previously published studies were used to define episodes. This was an exploratory study, and descriptive statistics were used to provide ADR rates and summarise episode features for the full period (2010-2018) as well as for the ICD-9-CM (2010-2016) and ICD -10-CM (2017-2018) eras.

RESULTS

Between 2010 and 2018, ADR occurred in 162,985 hospital episodes, corresponding to 1.00% of the total number of episodes during the same period. Higher rates were seen in the oldest age groups. In the same period, the mean annual rate of episodes related to ADR was 174.2/100,000 population. The episode rate (per 100,000 population) was generally higher in males, except in young adults (aged '15-20', '25-30' and '30-35' years), although the overall frequency of ADR in hospital episodes was higher in females.

CONCLUSIONS

Despite the ICD-10-CM transition, administrative health data in Portugal remain a feasible source for producing up-to-date estimates on ADR in hospitals. There is a need for future research to identify target recipients for preventive interventions and improve medication safety practices in Portugal.

Medication errors and associated factors among pediatric inpatients in public hospitals of gamo zone, southern Ethiopia

Background

Medication errors are the most common medical errors in the world. In particular, pediatric patients are more susceptible to severe injuries and death. Despite their multidimensional impact, medication errors are not recognized well in developing nations, including Ethiopia. Thus, this study aimed to assess the prevalence of medication errors and associated factors among pediatric inpatients in public hospitals of Gamo zone, southern Ethiopia.

Methods

A facility-based cross-sectional study was conducted among 416 pediatric inpatients from August 1, 2020, to February 30, 2021. Open data kit tools and Stata version 16.0 were used for data collection and analysis, respectively. Bivariable and multivariable analyses were performed to identify factors associated with medication errors. An adjusted odds ratio with a 95% confidence interval was computed and a P-value of <0.05 in the multivariable analysis was set to declare statistical significance.

Results

Overall, 69.5% (95% CI: 64.80, 73.86) of pediatric inpatients experienced medication errors. Unsuitable working environment (aOR: 2.40, 95% CI: 1.48, 3.91), child weight <5 Kg (aOR: 3.72, 95% CI: 1.79, 7.73), medication administered by diploma professionals (aOR: 2.10, 95% CI: 1.31, 3.36), parent involvement (aOR: 0.55, 95% CI: 0.33, 0.95), non-adherence with medication administration rights (aOR: 2.68, 95% CI: 1.32, 5.44) and hospital stay for >5 days (aOR: 1.83, 95% CI: 1.15, 2.93) were significantly associated with medication errors.

Conclusion

Medication errors were high among pediatric inpatients as compared to previous national studies. To reduce the occurrences of medication errors, it is critical to create a suitable working environment, arrange education and training opportunities for providers, involve families in the medication administration process, and strictly adhere to medication administration rights.

Drug-Related Hospital Admissions via the Department of Emergency Medicine: A Cross-Sectional Study From the Czech Republic

Background: Drug-related hospital admissions (DRAs) represent a significant problem affecting all countries worldwide. This study aimed to determine the prevalence and preventability of DRAs, identify the most common medications involved in DRAs, the most common clinical manifestations of DRAs and describe the preventability aspects of DRAs.

Methods: This cross-sectional study examined unplanned hospital admissions to the University Hospital Hradec Králové via the department of emergency medicine in August–November 2018. Data were obtained from electronic medical records. The methodology of DRA identification was adapted from the OPERAM DRA adjudication guide.

Results: Out of 1252 hospital admissions, 195 DRAs have been identified (145 related to treatment safety, 50 related to treatment effectiveness). The prevalence of DRAs was 15.6% (95% CI 13.6–17.6). The most common medication classes involved in DRAs related to treatment safety were Antithrombotic agents, Antineoplastic agents, Diuretics, Corticosteroids for systemic use, and Beta blocking agents. The most common medication classes involved in DRAs related to treatment effectiveness included Diuretics, Antithrombotic agents, Drugs used in diabetes, Agents acting on the renin-angiotensin system, and Lipid modifying agents. Gastrointestinal disorders were the leading causes of DRAs related to treatment safety, while Cardiac disorders were the leading causes of DRAs related to treatment effectiveness. The potential preventability of DRAs was 51%. The highest share of potential preventability in medication classes repeatedly involved in DRAs related to treatment safety was observed for Anti-inflammatory and antirheumatic products, Psycholeptics, and Drugs used in diabetes. Potentially preventable DRAs related to treatment safety were most commonly associated with inappropriate drug selection, inappropriate monitoring, inappropriate dose selection, and inappropriate lifestyle measures. On the contrary, DRAs related to treatment effectiveness were more commonly associated with medication nonadherence.

Conclusion: It should be emphasized that in most DRAs, medications were only a contributory reason of hospital admissions and that benefits and risks have to be carefully balanced. It is highlighted by the finding that the same medication classes (Antithrombotic agents and Diuretics) were among the most common medication classes involved in DRAs related to treatment safety and simultaneously in DRAs related to treatment effectiveness. The study highlighted that apart from problems related to prescribing, problems related to monitoring and patient-related problems represent significant preventability aspects.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Scoping Review of Studies Evaluating Frailty and Its Association with Medication Harm

Introduction

Frailty is associated with an increased risk of death and morbid events. Frail individuals are known to have multiple comorbidities which are often associated with polypharmacy. Whilst a relationship between polypharmacy and frailty has been demonstrated, it is not clear if there is an independent relationship between frailty and medication harm.

Aims

This scoping review aimed to identify and critically appraise studies evaluating medication harm in patients with frailty.

Methods

PubMed, EMBASE, CINAHL and Cochrane databases were searched from inception until 1 February 2021 using key search terms that are synonymous with frailty (such as frail and frail elderly) and medication harm (such as adverse drug events and adverse drug reactions). To be included, studies must have identified medication harm as a primary or secondary outcome measure, and used a frailty assessment tool to determine frailty, or clearly defined how frailty was assessed. Data were narratively synthesised and presented in tables. The checklist from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Heart, Lung, and Blood Institute was used to assess the quality and risk of bias of studies that met the inclusion criteria.

Results

Of 2685 retrieved abstracts, 24 underwent full-text review and nine studies met the inclusion criteria. Three studies were retrospective cohort studies, and six were prospective observational studies. Six studies comprised two distinct groups of frail and non-frail individuals, and the remaining three studies evaluated medication harm in an entirely frail population. Seven studies used validated frailty tools such as the Clinical Frailty Scale, Fried Frailty Index, and Fried Frailty Phenotype. Two studies measured frailty using self-defined criteria. Overall, frail individuals were at risk of medication harm with rates ranging between 18.7 and 77% across the nine studies. However, whether frailty is an independent predictor of medication harm remains uncertain, as this was only evaluated in one study. The risk of bias assessment identified limitations in methods and reporting with all nine studies.

Conclusion

This scoping review identified nine studies evaluating medication harm in frail patients. However, all were limited by the methodological quality and inadequate reporting of study factors. There are few high-quality studies that described a relationship between medication harm and frailty. More robust studies are required that examine the independent relationship between frailty and medication harm, after adjusting for all possible confounders and in particular polypharmacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00940-3.

A Worldwide Bibliometric Analysis of Published Literature on Medication Errors

OBJECTIVES

The aim of the study was to map the recent literature on medication error to monitor the state of research and explore emerging research fronts. Specifically, the co-occurrences analysis aimed to research the conceptual structure of the medication errors, whereas the coauthorship analysis aimed to research the "authorities" that influenced the academic and political discussion on medication errors.

METHODS

The search for relevant studies was carried out through the Scopus. To map and monitor the state of research on medication error, a preliminary analysis was conducted through the year of publication, type of article, and language. The count of citation shows the most relevant work among those included. Bibliometric analyses were conducted, such as coauthorship analysis and co-occurrences analysis.

RESULTS

The search strategy yielded 5393 articles. Of these, 1267 articles were included. Four main themes emerged from this bibliometric analysis: (a) the exploration of human factors related to health care professionals that increase the risk of medication error, (b) the investigation of behaviors and strategies that can prevent the error in the preparation and administration stage, (c) the analysis of the benefits related to the presence of the pharmacist in hospital settings, and (d) the exploration of the consequences of a medication error and/or adverse effects of drugs.

CONCLUSIONS

For the first time, a bibliometric analysis of medication errors research in the world has been conducted and demonstrated that there is a wealth of contributions already being made that are well aligned to the World Health Organization challenge.

Identification of drug-related problems followed by clinical pharmacist interventions in an outpatient pharmacotherapy clinic

WHAT IS KNOWN AND OBJECTIVE

Pharmacotherapy is an essential strategy for the treatment of many medical conditions especially chronic disease and often involves multiple medications being used simultaneously. Increasing the use of medications may pose some challenges to safe and effective drug therapy and if not identified and prevented by the pharmacists eventually can lead to drug-related problems (DRPs). The present study aimed to examine the incidence of DRPs in Iranian patients and to evaluate patients' adherence to the clinical pharmacist interventions as well as the physicians' acceptance of these recommendations.

METHODS

This study was conducted in a university-affiliated outpatient pharmacotherapy clinic over a 22-month period. Patients aged 18 years and older with at least one chronic disease receiving at least four medications were included in the study. The patients were interviewed by a clinical pharmacist for comprehensive medication review. DRPs were identified using the DOCUMENT classification system. Recommendations were provided by the clinical pharmacist including interventions involving patient and/or physician to resolve DRPs. The patients were followed up after 2 weeks to evaluate their compliance and physician acceptance of clinical pharmacist recommendations.

RESULTS AND DISCUSSION

Two hundred patients were included in this study. Overall, 875 DRPs were identified with an average of 4.37 per patient. The most prevalent DRPs were related to patient education or information (22.8%), undertreated indications (17.4%) and patient compliance (17.2%). The most common drugs associated with DRPs were alimentary and metabolism (22.2% of DRPs) followed by the cardiovascular system (19.2%) and nervous system (9.6%) medications. The DRP incidence correlated with gender only and was higher in females (p = 0.019). The clinical pharmacist provided 912 interventions with an average of 4.56 and 1.04 interventions per patient and per DRPs respectively. Patient education (41.3%), medication initiation or discontinuation (24.5%), and non-pharmacological interventions (12.9%) were the most common clinical pharmacist interventions. Out of 912 interventions, 665 were followed up, out of which 427 were patient dependent and 228 involved physicians. The patient's compliance with clinical pharmacist recommendations was 81.2%. The physician acceptance rate of the recommendations was 44.1%.

WHAT IS NEW AND CONCLUSION

The study shows that especially designed services such as pharmacotherapy clinics running by clinical pharmacists are necessary to detect and resolve DRPs in an effective way. The high compliance rate of the patients indicates patients' confidence in the clinical pharmacist services provided in the pharmacotherapy clinic. The low acceptance rate of the physicians highlights the need to improve interprofessional collaboration between clinical pharmacists and physicians in an outpatient setting.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Clinical usefulness of prediction tools to identify adult hospitalized patients at risk of drug-related problems: A systematic review of clinical prediction models and risk assessment tools

AIMS

This study aimed to review systematically all available prediction tools identifying adult hospitalized patients at risk of drug-related problems, and to synthesize the evidence on performance and clinical usefulness.

METHODS

PubMed, Scopus, Web of Science, Embase, and CINAHL databases were searched for relevant studies. Titles, abstracts and full-text studies were sequentially screened for inclusion by two independent reviewers. The Prediction Model Risk of Bias Assessment Tool (PROBAST) and the Revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklists were used to assess risk of bias and applicability of prediction tools. A narrative synthesis was performed.

RESULTS

A total of 21 studies were included, 14 of which described the development of new prediction tools (four risk assessment tools and ten clinical prediction models) and six studies were validation based and one an impact study. There were variations in tool development processes, outcome measures and included predictors. Overall, tool performance had limitations in reporting and consistency, with the discriminatory ability based on area under the curve receiver operating characteristics (AUROC) ranging from poor to good (0.62-0.81), sensitivity and specificity ranging from 57.0% to 89.9% and 30.2% to 88.0%, respectively. The Medicines Optimisation Assessment tool and Assessment of Risk tool were prediction tools with the lowest risk of bias and low concern for applicability. Studies reporting external validation and impact on patient outcomes were scarce.

CONCLUSION

Most prediction tools have limitations in development and validation processes, as well as scarce evidence of clinical usefulness. Future studies should attempt to either refine currently available tools or apply a rigorous process capturing evidence of acceptance, usefulness, performance and outcomes.

Methodological issues in research on drug-related admissions: A meta-epidemiological review with focus on causality assessments

AIM

To investigate methodological aspects potentially related to the diverging scientific literature on the prevalence of drug-related hospitalisations, focusing on causality assessments.

METHODS

Original studies contributing data to a recent meta-analysis were reviewed. Methodological aspects, in particular those related to causality assessments, were extracted and compiled.

RESULTS

Thirteen studies provided data on the prevalence of drug-related admissions. Seven studies focused on adverse drug reactions (prevalences 1.3-10%), and six studies used the broader concept of drug-related problems (prevalences 4.5-41%). In 10 out of 13 studies, causality between the drug and the specified problem was assessed. One study required a probable causal relationship; the remaining studies merely required a possible causal relationship. Five studies assessed the association between the problem assumed to be related to drug therapy and the admission, at one end requiring the former to be demonstrated as the underlying cause and, at the other, merely requiring a temporal relationship between drug intake and admission. Three out of eight studies involving multiple assessors for all/some cases reported the inter-rater agreement, ranging from none to almost perfect. Physicians were involved in the assessments in five studies, reporting prevalences of 3.2% to 4.5%, while studies without such medical input reported prevalences of 8.8% to 41%.

CONCLUSIONS

This review illustrates that methodological issues contribute to the diverse literature on drug-related admissions. We provide suggestions for harmonisation of research, including explicitly assessing the drug-problem-admission relationships from a medical perspective, focusing on problems where the drug treatment is the probable culprit.

Patient harm from cardiovascular medications

Background

Medication harm can lead to hospital admission, prolonged hospital stay and poor patient outcomes. Reducing medication harm is a priority for healthcare organisations worldwide. Recent Australian studies demonstrate cardiovascular (CV) medications are a leading cause of harm. However, they appear to receive less recognition as ‘high risk’ medications compared with those classified by the medication safety acronym, ‘APINCH’ (antimicrobials, potassium, insulin, narcotics, chemotherapeutics, heparin). Our aim was to determine the scale and type of medication harm caused by CV medications in healthcare.

Methods

A narrative review of adult (>16 years) medication harm literature identified from PubMed and CINAHL databases was undertaken. Studies with the primary outcome of measuring the incidence of medication harm were included. Harm caused by CV medications was described and ranked against other medication classes at four key stages of a patient’s healthcare journey. Where specified, the implicated medications and type of harm were investigated.

Results

A total of 75 studies were identified, including seven systematic reviews and three meta-analyses, with most focussing on harm causing hospital admission. CV medications were responsible for approximately 20% of medication harm; however, this proportion increased to 50% in older populations. CV medications were consistently ranked in the top five medication categories causing harm and were often listed as the leading cause.

Conclusion

CV medications are a leading cause of medication harm, particularly in older adults, and should be the focus of harm mitigation strategies. A practical approach to generate awareness among health professionals is to incorporate ‘C’ (for CV medications) into the ‘APINCH’ acronym.

Plain language summary

Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist

OBJECTIVES

Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs).

METHODS

A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling.

KEY FINDINGS

In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001).

CONCLUSIONS

Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

Knowledge and attitudes of healthcare professionals on prescribing errors

OBJECTIVES

This study aimed to evaluate the knowledge and attitudes of healthcare professionals on prescribing errors.

METHODS

This was a cross-sectional study employing a questionnaire that consisted of 12 items on knowledge and 10 items on healthcare professionals' attitudes toward errors in prescribing process. The participants responded to the questionnaire with a 5-Likert scale of agreement. The domains assessed in the questionnaire were respondents' knowledge and attitudes on prescribing errors, professionals responsible for the errors, and professionals' competence on drug dose adjustment. Additionally, the questionnaire had two case scenarios to further assess the healthcare professionals' knowledge of prescribing errors. There were 300 questionnaires administered to physicians, nurses, and pharmacists who attended conferences in Denpasar from July to October 2019.

RESULTS

There were 30 physicians, 58 nurses, and 69 pharmacists who responded to the survey. A response rate of 52.3% (157/300) was obtained. All healthcare professionals agreed that errors may occur in prescribing, dispensing, and administration process. All healthcare professionals understood that physician is responsible for ensuring drug safety in prescribing process and also supported a standardized form on drugs which may need drug dose personalization. Concerning item on the importance of collaboration in drug dose adjustment, although the healthcare professionals agreed on the statement, they had significant differences on the level agreement on the statement (p=0.029). The healthcare professionals also supported having regular training on drug dose adjustment based on individual patients' regimentation. The healthcare professionals' responses showed that the significant differences found on the statement of healthcare professionals should have competency on personalized dose calculation (p<0.001). All healthcare professionals agreed that physicians should have competency on drug dose adjustment, yet physicians showed less agreement that other health professionals should have the competency.

CONCLUSIONS

All healthcare professionals understood that medication errors may occur during the prescribing process but showed different attitudes on professionals who had competence in drug dose calculation. They emphasize the need to have a standardized prescription format for medication with dose changes. The respondents also recommend having regular training on medication safety for healthcare professionals.

Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions

BACKGROUND

Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians' and nurses' experiences from evaluations of older persons' medications, and their related actions to manage concerns related to the evaluations.

METHOD

Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique.

RESULTS

The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals' clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day work and planning for continued treatment) and collaborative problem-solving (e.g. finding a solution, involving the older person, and communicating with colleagues).

CONCLUSION

Working conditions and cooperation with colleagues, the older persons and their formal or informal caregivers, emerged as important factors related to the medication evaluation. By adjusting their performance to variations in these conditions, healthcare professionals contributed to the resilience of the healthcare system by its capacity to prevent, notice and mitigate medication problems. Based on these findings, we hypothesize that a joint plan for continued treatment could facilitate such resilience, if it articulates what to observe, when to act, who should act and what actions to take in case of deviations from what is expected.

Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade

INTRODUCTION

Pediatric medication therapy is prone to errors due to the need for pharmacokinetic and pharmacodynamic individualization and the diverse settings in which pediatric patients are treated. Prescribing errors have been reported as the most common medication error.

OBJECTIVES

The aim of this review was to systematically identify interventions to reduce prescribing errors and corresponding patient harm in pediatric healthcare settings and to evaluate their impact.

METHODS

Four databases were systematically screened (time range November 2011 to December 2019), and experimental studies were included. Interventions to reduce prescribing errors were extracted and classified according to a 'hierarchy of controls' model.

RESULTS

Forty-five studies were included, and 70 individual interventions were identified. A bundle of interventions was more likely to reduce prescribing errors than a single intervention. Interventions classified as 'substitution or engineering controls' were more likely to reduce errors in comparison with 'administrative controls', as is expected from the hierarchy of controls model. Fourteen interventions were classified as substitution or engineering controls, including computerized physician order entry (CPOE) and clinical decision support (CDS) systems. Administrative controls, including education, expert consultations, and guidelines, were more commonly identified than higher level controls, although they may be less likely to reduce errors. Of the administrative controls, expert consultations were most likely to reduce errors.

CONCLUSIONS

Interventions to reduce pediatric prescribing errors are more likely to be successful when implemented as part of a bundle of interventions. Interventions including CPOE and CDS that substitute risks or provide engineering controls should be prioritized and implemented with appropriate administrative controls including expert consultation.

Medication Without Harm: Developing optimal medication error reporting systems

Medication errors are amongst the most frequently occurring health care related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems which deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.

Population-Based Observational Study of Adverse Drug Event-Related Mortality in the Super-Aged Society of Japan

INTRODUCTION

Adverse drug events (ADEs) are a major cause of mortality.

OBJECTIVE

We examined long-term trends for ADE-related deaths in Japan.

METHODS

This observational study was conducted using the Japanese Vital Statistics from 1999 to 2016. Data for all ADE-related deaths were extracted using International Classification of Diseases, Tenth Revision codes. We analysed ADE-related deaths by age and sex and calculated crude and age-standardised mortality rates (ASMR) per 100,000 people. We used Joinpoint regression analysis to identify significant changing points in mortality trends and to estimate annual percentage change (APC).

RESULTS

In total, 16,417 ADE-related deaths were identified. The crude mortality rate for individuals aged ≥ 65 years was higher than that of young individuals. The ASMR per 100,000 people increased from 0.44 in 1999 to 0.64 in 2016. The crude mortality rate increased from 0.44 in 1999 to 1.01 in 2016. The APC of ASMR increased at a rate of 2.8% (95% confidence interval [CI] 1.4-4.2) throughout the study period. In addition, crude mortality increased at a rate of 5.7% (95% CI 4.2-7.3) annually from 1999 to 2016. The ADE-related mortality rate was higher for men than for women during the study period.

CONCLUSIONS

The number of and trend in ADE-related deaths increased in Japan from 1999 to 2016, particularly in the older population.

Assessment of the reliability of the IHI Global Trigger Tool: new perspectives from a Brazilian study

OBJECTIVE

To assess the reliability of the Institute for Healthcare Improvement's Global Trigger Tool (IHI-GTT) between nurses and medical students as primary reviewers to measure adverse events (AEs).

DESIGN

Interrater reliability study.

SETTING

A 500-bed general public hospital in Belo Horizonte, Brazil.

PARTICIPANTS

A randomly selected sample of 220 hospital admissions of adults (≥18 years) from Oct-Nov, 2016.

INTERVENTION

Two 4th-5th year-medical students and two experienced nurses applied a Portuguese-translated version of the IHI-GTT to medical records. The role of medical reviewer was performed by two senior physicians specialists in Internal Medicine.

MAIN OUTCOME MEASURES

Ability to identify AEs was compared between pairs and against medical reviewer through percentage inter-examiner agreement and Kappa coefficient (K). Two outcomes -- "AE identification" and "category of harm" -- were evaluated according to two different denominators  -- "admissions" (the total number of admissions evaluated in the sample; reflects the presence or not of at least one AE in each admission) and "all possibilities of agreement" (obtained by adding each identified AE to the admissions without events; allows agreement assessment to be performed for each AE individually).

RESULTS

Were identified 199 adverse events in 90 hospitalizations, with rates of 40.9% of admissions with AEs, 76.1 AEs/1,000 patient-days and 90.5 AEs/100 admissions. Comparing student-pair and nurse-pair, we found K = 0.76 (95% IC 0.62-0.88) and K = 0.17 (95% IC 0.06-0.27) for "AE identification" outcome and K = 0.28 (95% IC 0.01-0.55) and K = 0.46 (95% IC 0.28-0.64) for "category of harm" outcome to denominators "admission" and "all possibilities of agreement", respectively. There was no significant difference between the performances of the different primary reviewers composed in any analyses.

CONCLUSION

IHI-GTT reliability varies considerably depending on the denominator used to calculate agreement. As the purpose of the tool is, in addition to measuring, promoting opportunities for quality of care improvement, the individual analysis of the AEs seems more appropriate. Further studies are needed to assess the implications of the slight agreement reached between primary reviewers on the test's overall accuracy. Moreover, advanced medical students may be considered for primary review in settings where unavailability of staff is a barrier to IHI-GTT adoption.

Hospital medication errors: a cross-sectional study

BACKGROUND

Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia.

METHODS

A 5-year cross-sectional study.

RESULTS

The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%).

CONCLUSIONS

MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

Evaluation of the nature, severity, likelihood and preventability of medication-related hospital-acquired complications

Objective Pricing for safety and quality was introduced into Australian hospitals using a defined list of hospital-acquired complications (HACs). Medication-related HACs include drug-related respiratory complications (DRRC), haemorrhagic disorder due to circulating anticoagulants (HDDCA) and hypoglycaemia. The aim of this study was to determine the probability, severity and preventability of medication-related HACs, common contributory medications and themes, and whether medication-related HACs are a suitable data source to inform risk associated with medicines use. Methods Medical notes were reviewed retrospectively for all patients discharged from a tertiary referral metropolitan hospital between 1 July and 31 December 2018 who were flagged as experiencing a medication-related HAC. Naranjo, Hartwig's and Schumock and Thornton tools were used to assess the probability, severity and preventability of medication-related HACs. Results Over the 6-month period, 88 patients experienced a medication-related HAC. An HAC was not identified in five (5.7%) patient charts. The most common HAC was hypoglycaemia (n=59; 67%), followed by HDDCA (n=23; 26%) and DRRC (n=6; 7%). Fifteen patients (17%) flagged with a hypoglycaemia HAC were not on a medicine associated with hypoglycaemia. Overall, 6% (n=4) of HACs were severe, 72% (n=49) were moderate and 22% (n=15) were mild. Where the HAC and causal medication(s) were identified (n=68), over half were probable (51.5%, n=35) and 44.1% (n=30) were possible causes of the adverse drug reaction; only two (2.9%) were definite causes. None of the DRRC HACs was preventable. Over half the HDDCA HACs (52.2%; n=12) and almost half the hypoglycaemia HACs (46.2%; n=18) were not preventable. Common themes included appropriate anticoagulant agent, dose and monitoring, as well as periprocedural hypoglycaemic management, which considers oral intake and comorbidities. Conclusion Not all patients who experience medication-related HACs were on causative medications. Of those who were, medications were probable causal agents in over 50% of cases. Only a small number of HACs were severe and under half of medication-related HACs were preventable. What is known about the topic? The relationship between pricing for safety and quality and improvements in patient outcomes has shown mixed results. Medication-related harm is a problem within Australia and system-wide changes should be considered to improve patient care. What does this paper add? This paper adds evidence to the use of medication-related HACs as a source of data to inform risk associated with medicines use and provides details on the preventability and severity of medication-related HACs and the likelihood that medicines contribute to these complications. What are the implications for practitioners? This paper provides clinicians and policy makers details on the utility of using medication-related HACs as a measure of risk associated with medicines use. It discusses merit in using HACs as a source for quality improvement, but recommends that definitions may need to be reviewed to enhance utility.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

BACKGROUND

Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety.

METHODS

Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted.

RESULTS

In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.

CONCLUSIONS

Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.