TABLE 5-1 Frequency of Adverse Drug Events by Cause

Class

Percent

Description

Preventable

Allergic reaction with no prior history

28.0

Allergic or idiosyncratic reactions in patients with no prior history of allergy

Unclear

Renal dysfunction

23.0

Failure to adjust dosage in the face of declining renal function, among drugs excreted through the kidneys

Yes

Patient age

14.2

Failure to adjust dosage for patient age

Yes

Patient weight

5.7

Failure to adjust dosage for patient body mass

Yes

Dosage error

5.0

Simple error in dosage ordered (excluding other sources on this list)

Yes

Hematologic factors

4.6

Failure to appropriately adjust for other known hematological factors

Yes

Patient compliance

3.8

Failure of patient to comply with medical instructions

Unclear

Drug administration rate

2.7

Error on rate of administration of medication

Yes

Liver dysfunction

2.3

Failure to appropriately adjust for reduced liver function, for hepatically excreted drugs

Yes

Known allergies

1.5

Failure to recognize and respond to known allergies

Yes

Electrolyte imbalances

1.5

Failure to appropriately adjust dosage for known electrolyte imbalances

Yes

Dosage schedule error

1.5

Error on medication order regarding dosing schedule

Unclear

NOTE: The first cause accounted for 28 percent of all events recorded; the second an additional 23 percent. Among almost 40 causes originally hypothesized in the cause-and-effect diagram, the first 6 shown here accounted for 80 percent of all ADEs detected.

Deployment and Implementation

“Pilot and deploy” is an approach to implementing improvements that has been successful in a number of care delivery organizations. The idea is simple: choose an important systemwide safety problem; then determine methods for achieving demonstrated performance within a small group using rapid-cycle improvement tools. A small group often avoids larger organizational change issues and thus can discover effective process steps more rapidly. Once the necessary process steps are known, they can be implemented in other parts of the organization. Demonstrated success in the pilot



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