. "5 Comprehensive Patient Safety Programs in Health Care Settings." Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press, 2004.
The following HTML text is provided to enhance online
readability. Many aspects of typography translate only awkwardly to HTML.
Please use the page image
as the authoritative form to ensure accuracy.
Patient Safety: Achieving a New Standard for Care
TABLE 5-2 Major Causes of Adverse Drug Events
ADE
Alert
Location
True Positive Rate (%)
% of All ADEs Detected
Cumulative % Detected
1.
Use of naloxone
Pharmacy
21.9
28.3
28.3
2.
Use of benadryl
Pharmacy
21.0
20.8
49.1
3.
Use of inapsine
Pharmacy
39.2
20.4
69.5
4.
Use of lomotil
Pharmacy
26.8
7.5
77.0
5.
Nurse reports of rash/itching
Nurse reporting
17.9
5.1
82.1
6.
Use of loperamide
Pharmacy
22.3
3.4
85.5
7.
Test for c.difficile toxin
Clinical laboratory
24.3
3.1
88.6
8.
Digoxin level > 2
Clinical laboratory
2.3
2.2
90.8
9.
Abrupt med. stop/reduction
Pharmacy
48.0
1.0
91.8
10.
Use of vitamin K
Pharmacy
4.8
0.9
92.7
11.
Doubling of blood creatinine
Clinical laboratory
0.4
0.8
93.5
12.
Use of kaopectate
Pharmacy
21.8
0.7
94.2
13.
Use of paregoric
Pharmacy
9.8
0.7
95.0
14.
Use of flumazenil
Pharmacy
77.3
0.7
95.7
FIGURE 5-3 Detected ADE rates at a large teaching hospital, as a more effective detection system was put in place (1988–1990) and as a series of medication ordering, delivery, and follow-up systems were implemented (1994–1999). Comparing 1990–1993 (preintervention period) with 1997–1999 (postintervention period), the detected ADE rate fell from 571 to 274 ADEs per year on average—a 52 percent decline.
