Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. Issue 1 (25th January 2021)

• Record Type: Journal Article
• Authors: de Lemos, Jane; Loewen, Peter; Nagle, Cheryl; McKenzie, Robert; You, Yong Dong; Dabu, Anna; Zed, Peter; Ling, Peter; Chan, Richard
• Is Part Of: BMJ open quality. Volume 10:Issue 1(2021)
• Publication Date: 2021-01-25
• Subjects: adverse events -- epidemiology and detection -- root cause analysis -- medication safety -- emergency department; Medical care -- Quality control -- Periodicals; 362.106805
• DOI: 10.1136/bmjoq-2020-001161
• Languages: English
• ISSNs: 2399-6641

Abstract

Abstract : Objectives: To identify root causes of preventable adverse drug events (pADEs) contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community. Methods: Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported. Results: Most common pADE-related medical conditions: chronic obstructive pulmonary disease/asthma (13.3%), bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%) and pneumonia (5%). Most common root causes were: providers not confirming that the patient/family understands information given (29.2%), can identify how a medication helps them/have their concerns addressed (16.7%), can identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%); absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented. Conclusions: To prevent pADEs, providers need to confirm that patients/families understand information given, how a medication helps them, how to recognise and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient's/families' medication use and monitoring competency.