TABLE 3-8 Distribution of Errors by System Failure

 

Errors Attributed

System Failure

%

No.

Drug knowledge dissemination

29

98

Dose and identity checking

12

40

Patient information availability

11

37

Order transcription

9

29

Allergy defense

7

24

Medication order tracking

5

18

Interservice communication

5

17

Device use

4

12

Standardization of doses and frequencies

4

12

Standardization of drug distribution within unit

3

11

Standardization of procedures

3

10

Preparation of intravenous medications

2

6

Transfer/transition procedures

1

4

Conflict resolution

1

4

Others

4

12

TOTALS

100

334

SOURCE: Leape et al., 1995.

lower bounds since the second Brigham and Women’s study (Jha et al., 1998), using more comprehensive detection methods, reported higher rates.

  • A high proportion of preventable ADEs are caused by system errors that could be eliminated by computerized provider order entry (CPOE).

  • Sophisticated decision-support tools that address dosing, prophylaxis, and patient monitoring, among other issues, must be built into CPOE systems.

Nursing Homes

Two studies estimated the incidence of preventable ADEs in long-term care (see Table 3-9). Their findings were as follows:

TABLE 3-9 Rates of Preventable ADEs in Nursing Homes

Study

Preventable ADE Rate per Patient Month

Proportion of ADEs Preventable (No. of ADEs in study)

ADEs per 100 Admissions

Gurwitz et al., 2000

0.01

51% (546)

0.02

Gurwitz et al., 2005

0.04

42% (815)

0.1



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