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.



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