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To Err Is Human: Building a Safer Health System (2000)

Chapter: C Literature Summary

« Previous: B Glossary and Acronyms
Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 215

C—
Literature Summary

This Appendix summarizes the literature described in Chapter 2. The references cited are at the end of Chapter 2.

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 216

TABLE C-1 Literature Summary

Reference

Sample Description

Data Source

General studies of errors and adverse events

   

Thomas et al., forthcoming 2000

Randomly sampled 15,000 nonpsychiatric 1992 discharges from a representative sample of hospitals in Utah and Colorado.

Chart review by trained nurses and board-certified family practitioners and internists.

Bhasale et al., 1998 Analysing potential harm in Australian general practice

A non-random sample of 324 general practitioners reporting incidents between October 1993 and June 1995.

General practitioner-reported free-text descriptions of incidents and answered fixed-response questions.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Reference

Results

Definition(s)

Causes/Types of Error

General studies of errors and adverse events

     

Thomas et al., forthcoming 2000

Adverse events occurred in 2.9% ± 0.2 of hospitalizations in each state. 32.6% ± 4 of adverse events were due to negligence in Utah and 27.4 ± 2.4 were due to negligence in Colorado. Death occurred in 6.6% ± 1.2 of adverse events and 8.8% ± 2.5 of negligent adverse events. The leading cause of nonoperative adverse events were adverse drug events (19.3% of all adverse events; 35.1% were negligent). Operative events comprised 44.9% of all adverse events and 16.9% were negligent.

Adverse event—''an injury caused by medical management (rather than the disease process) that resulted in either a prolonged hospital stay or disability at discharge."
Negligence was defined as "care that fell below the standard expected of physicians in their community."

46.1% of adverse events (22.3% negligent) were attributable to surgeons and 23.2% (44.9% negligent) were attributable to internists.

Bhasale et al., 1998 Analysing potential harm in Australian general practice

805 incidents were reported. 76% were preventable and 27% had potential for severe harm.

Incident—"an unintended event, no matter how seemingly trivial or commonplace, that could have harmed or did harm a patient."

Pharmacological management related to 51 per 100 incidents. Poor communication between patients and healthcare professionals and actions of others contributed to 23 per 100 incidents each. Errors in judgment contributed to 22 per 100 incidents.

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 218

TABLE C-1 Continued

Reference

Sample Description

Data Source

General studies of errors and adverse events (continued)

   

Leape et al., 1993
Preventing medical injury

Record review of 1,133 patients who suffered from an adverse event (AE).

Harvard Medical Practice Study.

McGuire et al., 1992
Measuring and managing quality of surgery

44,603 consecutive major operations performed at a large medical center from 1977 to 1990.

Resident reports giving name and procedure of each patient who suffered any complication. In a monthly conference, representatives of all specialties determined by consensus the category of each complication (inevitable, inherent risk, error, hospital deficit, coincidence, unknown).

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

General studies of errors and adverse events (continued)

     

Leape et al., 1993
Preventing medical injury

70% of adverse events were found to be preventable, 24% unpreventable, and 6% potentially preventable.

AE—per Leape (1991), AE is defined as "an unintended injury that was caused by medical management and that resulted in measurable disability."
Preventable AE—an AE resulting from an error.
Unpreventable AE—an AE resulting from a complication that cannot be prevented at the current state of knowledge.
Potentially preventable AE—an AE where no error was identified but it is widely recognized that a high incidence of this type of complication reflects low standards of care or technical expertise.

The most common types of preventable errors were technical errors (44%), errors in diagnosis (17%), failures to prevent injury (12%), and errors in the use of a drug (10%). Approximately 20% of technical errors, 71% of diagnostic errors, 50% of preventative errors, and 37% of errors in the use of a drug were judged to be negligent.

McGuire et al., 1992
Measuring and managing quality of surgery

2,428 patients (5.4%) suffered 2,797 complications (6.3%). 49% of these complications were attributable to error. 749 patients (1.7%) died during the same hospitalization. 7.5% of these deaths were attributable to error.

   

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 220

TABLE C-1 Continued

Reference

Sample Description

Data Source

General studies of errors and adverse events (continued)

   

Bedell et al., 1991
Incidence and characteristics of preventable iatrogenic cardiac arrests

203 patients who suffered from cardiac arrest at a teaching hospital during 1981.

At least one of the authors evaluated patients who underwent CPR within 24 hours of arrest. Information from the medical record was also used.

Leape et al., 1991
The nature of adverse events in hospitalized patients

30,195 randomly selected records in 51 hospitals in New York state (1984).

Hospital records.

DuBois et al., 1988
Preventable Deaths

182 deaths from 12 hospitals for 3 conditions (cerebrovascular accident, pneumonia, or myocardial infarction)

Investigators prepared a dictated summary of each patient's hospital course. Panels of 3 physicians for each condition then independently reviewed each summary and independently judged whether the death was preventable.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

General studies of errors and adverse events (continued)

     

Bedell et al., 1991
Incidence and characteristics of preventable iatrogenic cardiac arrests

28 (14%) of arrests followed an iatrogenic complication. 17 (61%) of the 28 patients died. All 4 reviewers considered 18 (64%) of the iatrogenic arrests to have been preventable.

latrogenic cardiac arrest—"an arrest that resulted from a therapy or procedure or from a clearly identified error of omission."

The most common causes of potentially preventable arrest were medication errors and toxic effects (44%), and suboptimal response by physicians to clinical signs and symptoms (28%).

Leape et al., 1991
The nature of adverse events in hospitalized patients

1,133 adverse events (AEs) occurred in 30,195 patients.

AE—"an unintended injury that was caused by medical management and that resulted in measurable disability."

Drug complications were the most common type of adverse event (19%), followed by wound infections (14%) and technical complications (13%). 58% of the adverse advents were errors in management, among which nearly half were attributable to negligence.

DuBois et al., 1988
Preventable Deaths

The physicians unanimously agreed that 14% of the deaths could have been prevented. 2 out of the 3 physicians found that 27% might have been prevented.

 

Preventable deaths from myocardial infarction reflected errors in management, from cerebrovascular accident reflected errors in diagnosis, and from pneumonia reflected errors in management and diagnosis.

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 222

TABLE C-1 Continued

Reference

Sample Description

Data Source

General studies of errors and adverse events (continued)

   

Steel et al., 1981
latrogenic illness on a general medical service at a university hospital

815 consecutive patients on a university hospital's general medical service during a 5-month period in 1979

Record review, clinical personnel interviews, and information from utilization-review coordinators.

Cooper et al., 1978
Preventable anesthesia mishaps

47 interviews regarding preventable mishaps between September 1975 and April 1977 including staff and resident anesthesiologists from a large urban teaching hospital.

Interviewees selected at random from a list of departmental members.

Dripps et al., 1961
The role of anesthesia in surgical mortality

Records of 33,224 patients anesthetized in a 10-year period.

Patient records

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

General studies of errors and adverse events (continued)

     

Steel et al., 1981
latrogenic illness on a general med

36% of patients had an iatrogenic illness. 9% of the patients had an iatrogenic illness that threatened life or produced considerable disability while, in another 2%, the illness was believed to contribute to the death of the patient.

latrogenic illness—"any illness that resulted from a diagnostic procedure or from any form of therapy." In addition, the authors included harmful occurrences (e.g., injuries from a fall or decubitus ulcers) that were not natural consequences of the patient's disease.

 

Cooper et al., 1978
Preventable anesthesia mishaps

359 preventable critical incidents were identified and coded.

Critical incident—a mishap that "was clearly an occurrence that could have led (if not discovered or corrected in time) or did lead to an undesirable outcome, ranging from increased length of hospital stay to death or permanent disability."

82% of the preventable incidents reported involved human error and 14% involved equipment error.

Dripps et al., 1961
The role of anesthesia in surgical mortality

12 of the 18,737 patients who received spinal anesthesia died from causes definitely related to the anesthetic (1:1,560). 27 of the 14,487 patients who received general anesthesia supplemented with a muscle relaxant died from causes directly related to the anesthetic (1:536).

   

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 224

TABLE C-1 Continued

Reference

Sample Description

Data Source

General studies of errors and adverse events (continued)

   

Beecher and Todd, 1954
A study of the deaths associated with anesthesia and surgery based on a study of 599,548 anesthesias in ten institutions

All deaths from January 1, 1948, through December 31, 1952, occurring on the surgical services of 10 university hospitals.

1 team, consisting of an anesthesiologist, a surgeon, and a secretary, worked in each of the 10 hospitals and appraised the causes of all deaths on the surgical services.

Medication-related studies

   

Knox, 1999
Prescription errors tied to lack of advice
Globe article

Analysis of medication errors by 51 Massachusetts pharmacists.

 

Leape, 1999
Pharmacist participation on physician rounds and adverse drug events in the intensive care unit

75 patients randomly selected from each of 3 groups: all admissions to the study unit (2 medical ICUs at Massachusetts General Hospital) from February 1, 1993, through July 31, 1993 (baseline), and all admissions to the study unit (postintervention) and control unit from October 1, 1994, through July 7, 1995.50 patients were also selected at random from the control unit during the baseline period.

Review of medical records and pharmacist recommendations.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 225

(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

General studies of errors and adverse events (continued)

     

Beecher and Todd, 1954
A study of the deaths associated with anesthesia and surgery based on a study of 599,548 anesthesias in ten institutions

7,977 of the 599,548 patients who received anesthesia died. Gross errors in anesthetic management occurred in 29 of the 384 (7.6%) deaths caused by anesthesia.

   

Medication-related studies

     

Knox, 1999
Prescription errors tied to lack of advice
Globe article

88% of medication errors involved the wrong drug or the wrong dose and 63% involved first-time prescriptions rather than refills.

 

Pharmacists cited factors that led to mistakes. 62% cited "too many telephone calls," 59% "unusually busy day," 53% ''too many customers," 41% "lack of concentration," and 32% "staff shortage."

Leape, 1999
Pharmacist participation on physician rounds and adverse drug events in the intensive care unit

The rate of preventable adverse drug events (ADEs) due to ordering decreased by 66% from 10.4 per 1,000 patient days before the intervention to 3.5 per 1,000 patient days after the intervention.
The rate was essentially unchanged during the same time periods in the control unit: 10.9 and 12.4 per 1,000 patient days.

ADE—per Bates (1993), ADE is defined as "an injury resulting from the administration of a drug."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 226

TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Lazarou, 1998
Incidence of adverse drug reactions in hospitalized patients

39 prospective studies from U.S. hospitals.

4 electronic databases were searched for articles between 1966 and 1996.

Wilson et al., 1998
Medication errors in paediatric practice

682 children admitted to a Congenital Heart Disease Center at a teaching hospital in the United Kingdom.

Standardized incident report forms filled out by doctors, nurses, and pharmacists.

Andrews et al., 1997
An alternative strategy for studying adverse drug events

1,047 patients admitted to 3 units at a large, tertiary care, urban teaching hospital affiliated with a university medical school.

Ethnographers trained in qualitative observational research recorded all adverse events discussed while attending day-shift, weekday, regularly scheduled attending rounds, residents' work rounds, nursing shift changes, case conferences, and other scheduled meetings.

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Lazarou, 1998
Incidence of adverse drug reactions in hospitalized patients

The overall incidence of serious adverse drug reactions (ADRs) in hospitalized patients was 6.7% and of fatal ADRs was 0.32%. In 1994, an estimated 2,216,000 hospitalized patients experienced serious ADRs and 106,000 had fatal ADRs, making these reactions the fourth and sixth leading causes of death.

ADR—"According to the World Health Organization definition, this is any noxious, unintended, and undesired effect of a drug, which occurs at doses in humans for prophylaxis, diagnosis, or therapy. This definition excludes therapeutic failures, intentional and accidental poisonings (i.e., overdose), and drug abuse. Also, this does not include adverse events due to errors in drug administration or noncompliance (taking more or less of a drug than the prescribed amount)."

 

Wilson et al., 1998
Medication errors in paediatric practice

441 medical errors were reported. Prescription errors accounted for 68% of all reported errors, administration errors for 25%, and supply errors for 7%.

Medication error—"a mistake made at any stage in the provision of a pharmaceutical product to a patient."

Doctors accounted for 72% of the errors, nurses for 22%, pharmacy staff for 5%, and doctor/nurse combination for 1%

Andrews et al., 1997
An alternative strategy for studying adverse drug events

An adverse event occurred in 480 of the 1,047 patients (45.8%). 185 of the patients (17.7%) had at least one serious event. The likelihood of experiencing an adverse event increased approximately 6% for each day of a hospital stay. Only 1.2% of the patients experiencing serious events made claims to compensation.

Adverse event—a situation "in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen."

Individuals caused 37.8% of adverse events while 15.6% of the events had interactive causes and 9.8% were due to administrative decisions.

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 228

TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Classen et al., 1997
Adverse drug events in hospitalized patients

Matched case-control study of all patients admitted to LDS Hospital (a tertiary care institution) from January 1, 1990, to December 31, 1993, and who had confirmed adverse drug events (ADEs). Controls and cases were matched on age, sex, acuity, year of admission, and primary discharge diagnosis related group (DRG).

Nursing acuity system and primary discharge DRG.

Cullen et at., 1997
Preventable adverse drug events in hospitalized patients

Prospective cohort study of 4,031 adult admissions to a stratified, random sample of 11 medical and surgical units (including 2 medical and 3 surgical ICUs and 4 medical and 2 surgical general care units) in 2 tertiary care hospitals over a 6-month period.

Stimulated self-report by nurses and pharmacists and daily review of all charts by nurse investigators. 2 independent reviewers classified the incidents.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 229

(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Classen et al., 1997
Adverse drug events in hospitalized patients

ADEs complicated 2.43 per 100 admissions. The occurrence of an ADE was associated with an increased length of stay of 1.91 days and an increased cost of $2,262. The increased risk of death among patients experiencing an ADE was 1.88. Almost 50% of all ADEs are potentially preventable.

ADE—an event that is "noxious and unintended and occurs at doses used in humans for prophylaxis, diagnosis, therapy, or modification of physiologic functions."

 

Cullen et at., 1997
Preventable adverse drug events in hospitalized patients

The rate of preventable adverse drug events (ADEs) and potential ADEs in ICUs was 19 events per 1,000 patient days. This was nearly twice the rate of non-ICUs, but, when adjusted for the number of drugs used in the previous 24 hours or ordered since admission, there were no differences in rates between ICUs and non-ICUs.

ADE—"an injury resulting from medical intervention related to a drug."
Potential adverse drug event—an incident "with potential for injury related to the use of a drug."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Lesar et al., 1997
Factors related to errors in medication prescribing

Every third prescribing error detected and averted by pharmacists in a 631-bed tertiary care teaching hospital between July 1, 1994, and June 30, 1995.

Retrospective evaluation by a physician and 2 pharmacists.

Schneitman-Mclntire et al., 1996
Medication misadventures resulting in emergency department visits at an HMO medical center

Records of 62,216 patients who visited the emergency department of a California HMO between August 1992 and August 1993

Patient records and pharmacist interviews with patients.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Lesar et al., 1997
Factors related to errors in medication prescribing

2,103 errors thought to have potential clinical importance were detected, and the overall rate of errors was 3.99 errors per 1,000 medication orders.

 

The most common factors associated with errors were decline in renal or hepatic function requiring alteration of drug therapy (13.9%), patient history of allergy to the same medication class (12.1%), using the wrong drug name, dosage, form, or abbreviation (11.4% for both brand and generic name orders), incorrect dosage calculations (11.1 %), and atypical or unusual and critical dosage frequency considerations (10.8%). The most common group factors associated with errors were those related to knowledge and the application of knowledge regarding drug therapy (30%); knowledge and use of knowledge regarding patient factors that affect drug therapy (29.2%); use of calculations, decimal points, or unit and rate expression factors (17.5%); and nomenclature factors, such as incorrect drug name, dosage form, or abbreviation (13.4%).

Schneitman-Mclntire et al., 1996
Medication misadventures resulting in emergency department visits at an HMO medical center

1,074 or 1.7% of the emergency department visits were due to medication misadventures. Of the 1,074 misadventures, 152 (14.1%) resulted in hospital admissions.

Misadventures "included noncompliance and inappropriate prescribing but excluded intentional overdoses and substance abuse."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 232

TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Bates et al., J Gen Intern Med, 1995
Relationship between medication errors and adverse drug events

A cohort of 379 consecutive admissions during a 51-day period in three medical units of an urban tertiary care hospital.

Self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. 2 independent reviewers classified the incidents.

Bates et al., JAMA, 1995
Incidence of adverse drug events and potential adverse drug events

4,031 adult admissions to a stratified random sample of 11 medical and surgical units in Brigham and Women's Hospital (726 beds) and Massachusetts General Hospital (846 beds) in Boston over a 6-month period between February and July 1993.

Stimulated self-reports by nurses and pharmacists and daily chart review. 2 independent reviewers classified the incidents.

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Bates et al., J Gen Intern Med, 1995
Relationship between medication errors and adverse drug events

10,070 medication orders were written, and 530 medication errors were identified (5.3 errors/100 orders). 25 adverse drug events (ADEs) and 35 potential ADEs were found. 20% of the ADEs were associated with medication errors; all were judged preventable. 5 of 530 (0.9%) medication errors resulted in ADEs.
Physician computer order entry could have prevented 86% of potential ADEs, 84% of non-missing dose medication errors, and 60% of preventable ADEs.

ADE—an injury "resulting from medical interventions related to a drug."
Potential ADE—a medication error "with potential for injury but in which no injury occur-red."
Medication error—an error "in the process of ordering or delivering a medication, regardless of whether an injury occurred or the potential for injury was present."

 

Bates et al., JAMA, 1995
Incidence of adverse drug events and potential adverse drug events

247 adverse drug events (ADEs) and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 1,000 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1,900 ADEs and 1,600 potential ADEs. 1% of all ADEs were fatal, 12% life-threatening, 30% serious, and 57% significant. 28% of all ADEs were judged preventable.

ADE—"an injury resulting from medical intervention related to a drug."
Potential ADE—an incident "with potential for injury related to a drug."

56% of preventable ADEs occurred at the ordering stage, 34% at administration, 6% during transcription, and 4% during dispensing.

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 234

TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Cullen et al., 1995
The incident reporting system does not detect adverse drug events

All patients admitted to five patient care units in an academic tertiary care hospital between February and July 1993.

Consensus voting by senior hospital administrators, nursing leaders, and staff nurses.

Leape et al., 1995
Systems analysis of adverse drug events

All nonobstetric adult admissions to 11 medical and surgical units in 2 tertiary care hospitals in the period between February and July 1993.

Reports from each unit solicited daily by trained nurse investigators and peer interviews. 2 independent reviewers classified the incidents.

Willcox et al., 1994
Inappropriate drug prescribing for the community dwelling elderly

6,171 adults from a cross-sectional survey of a national probability sample of individuals aged 65 or older.

1987 National Medical Expenditure Survey.

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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(table continued from previous page)

Reference

Results

Definition(S)

Causes/Types of Error

Medication-related studies (continued)

     

Cullen et al., 1995
The incident reporting system does not detect adverse drug events

Incident reports were submitted to the hospital's quality assurance program or called into the pharmacy hotline for 3 of the 54 people experiencing adverse drug events (ADEs). 15 (28%) of the ADEs were preventable and 26 (48%) were serious or life-threatening.

ADE—''an injury resulting from the use of a drug."

 

Leape et al., 1995
Systems analysis of adverse drug events

334 errors were detected as the causes of 264 preventable adverse drug events (ADEs) and potential ADEs.

Potential ADEs—"errors that have the capacity to cause injury, but fail to do so, either by chance or because they are intercepted,"

16 major system failures were identified as the causes of the errors, of which the most common was dissemination of drug knowledge (29% of 334 errors). 7 systems failures accounted for 78% of errors.

Willcox et al., 1994
Inappropriate drug prescribing for the community dwelling elderly

23.5% of people aged 65 years or older, or 6.64 million Americans, received at least 1 of the 20 contraindicated drugs in 1987. 20.4% received two or more such drugs.

Contraindicated drugs include:
1) chlordiazepoxide
2) diazepam
3) flurazepam
4) meprobamate
5) pentobarbital
6) secobarbital
7) amitriptyline
8) indomethacin
9) phenylbutazone
10) chlorpropamide
11) propoxyphene
12) pentazocine
13) cyclandelate
14) isoxsuprine
15) dipyridamole
16) cyclobenzaprine
17) orphenidrat
18) methocarbamol
19) carisoprodol
20) trimethobenzamide

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 236

TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Bates et al., 1993
Incidence and preventability of adverse drug events in hospitalized adults

All patients admitted to 2 medical, 2 surgical, and 2 obstetric general care units and 1 coronary intensive care unit over a 37-day period in an urban tertiary care hospital.

Records entered into logs in each unit and satellite pharmacies by nurses and pharmacists, reports solicited by a research nurse twice daily on each unit, and chart review by the nurse.

Einarson, 1993
Drug-related hospital admissions

English-language studies of humans admitted to the hospital because of adverse drug reactions (ADRs) resulting from a patient's noncompliance or unintentionally inappropriate drug use.

Manual and computerized literature searches using MEDLINE, Index Medicus, and International Pharmaceutical Abstracts as databases

(table continued on next page)

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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(table continued from previous page)

Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Bates et al., 1993
Incidence and preventability of adverse drug events in hospitalized adults

73 drug-related incidents occurred in 2,967 patient days. 27 incidents were judged adverse drug events (ADEs), 34 potential ADEs, and 12 problem orders. 5 of the 27 ADEs were life-threatening, 9 were serious, and 13 were significant. 15 of the 27 ADEs (57%) were judged definitely or probably preventable.

ADE—"an injury resulting from the administration of a drug."
Potential ADE—an incident "with a potential for injury related to a drug ... [and an incident] in which a potentially harmful order was written but intercepted before the patient actually received the drug."
Problem order—"an incident in which a drug-related error was made, but was judged not to have the potential for injury."

Physicians caused 72% of the incidents, with the remainder divided evenly between nursing, pharmacy, and clerical personnel.

Einarson, 1993
Drug-related hospital admissions

Between 1996 and 1989, adverse drug reaction (ADR) rates from 49 hospitals or groups of hospitals in international settings were published in 37 articles. Drug-induced hospitalizations account for approximately 5% of all admissions. Reported admissions caused by ADRs ranged from 0.2% to 21.7%, with a median of 4.9% and a mean of 5.5%. 3.7% of patients admitted for ADRs died.

ADR—"any unintended or undesired consequence of drug therapy."
Noncompliance—"any deviation from the regimen written (and intended) by the prescriber."

11 reports indicated that noncompliance induced 22.7% of ADR hospitalizations.

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Brennan et al., 1991
Incidence of adverse events and negligence in hospitalized patients

30,195 randomly selected records in 51 hospitals in New York state (1984).

Hospital records.

Classen et al., 1991
Computerized surveillance of adverse drug events in hospital patients

36,653 hospitalized patients in the LDS Hospital, Salt Lake City between May 1, 1989, and October 31, 1990.

Integrated hospital information system and pharmacist review of medical records.

Beers et al., 1990
Potential adverse drug interactions in the emergency room

424 randomly selected adults who visited the emergency room at a university-affiliated hospital. All subjects were discharged without hospital admission.

Complete emergency department record on every patient.

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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Brennan et al., 1991
Incidence of adverse events and negligence in hospitalized patients

Adverse events (AEs) occurred in 3.7% of the hospitalizations. Although 70.5% gave rise to disabilities lasting less than 6 months, 2.6% of the adverse events caused permanently disabling injuries and 13.6% resulted in death.

AE—"an injury that was caused by medical mismanagement (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both."

 

Classen et al., 1991
Computerized surveillance of adverse drug events in hospital patients

731 verified adverse drug events (ADEs) occurred in 648 patients. 701 ADEs were classified as moderate or severe. Physicians, pharmacists, and nurses voluntarily reported 92 of the 731 ADEs detected using the automated system. The remaining 631 were detected from automated signals, the most common of which were diphenhydramine hydrochloride and naloxone hydrochloride use, high serum drug levels, leukopenia, and the use of phytonadione and antidiarrheals.

ADE—an event that is "noxious and unintended and occurs at doses used in man for prophylaxis, diagnosis, therapy, or modification of physiologic functions." "Therapeutic failures, poisonings, and intentional overdoses" were excluded.

 

Beers et al., 1990
Potential adverse drug interactions in the emergency room

47% of visits led to added medication. In 10% of the visits in which at least one medication was added, a new medication added a potential adverse interaction.

"Drug interactions are an aspect of the inappropriate use of medication that may endanger patients and that may be avoided by more careful prescribing."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Hallas et al., 1990
Drug related admissions to a cardiology department

366 consecutive patients admitted to the cardiology department at Odense University Hospital, Denmark, during a 2-month period (May–June 1988).

Written and verbal histories and blood samples.

Lesar et al., 1990
Medication prescribing errors in a teaching hospital

289,411 medication orders written between January 1, 1987, and December 31, 1987, in a tertiary care teaching hospital.

Medication orders reviewed by a centralized staff of pharmacists and the prescribing physicians.

Sullivan et al., 1990
Noncompliance with medication regimens and subsequent hospitalizations

7 studies and 2,942 admissions with comparable methodologies and evaluation regarding the extent and direct cost of hospital admissions related to drug therapy noncompliance.

Meta-analytic literature review.

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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Hallas et al., 1990
Drug related admissions to a cardiology department

"Definite" or "probable" drug events accounted for 15 admissions, or a 4.1% drug-related hospitalization rate. 11 were due to adverse drug reactions (ADRs) and 4 to dose-related therapeutic failures (DTFs). Of these 15 admissions, 5 cases were judged to have been "definitely avoidable."

ADR—"any unintended and undesirable effect of a drug."
DTF—''lack of therapeutic effect that could be linked causally to either too low a prescribed dose, noncompliance, recent dose reduction/discontinuation, interaction or inadequate monitoring."

Of the 15 admissions, 5 were considered to be due to a prescription error.

Lesar et al., 1990
Medication prescribing errors in a teaching hospital

905 prescribing errors were detected and averted, of which 57.7% had a potential for adverse consequences. The overall error rate was 3.13 errors for each 1,000 orders written and the rate of significant errors was 1.81 per 1,000 orders.

Medication errors—
"medication orders for the wrong drug, inappropriate dosage, inappropriate frequency, inappropriate dosage form, inappropriate route, inappropriate indication, ordering of unnecessary duplicate/redundant therapy, contraindicated therapy, medications to which the patient was allergic, orders for the wrong patient, or orders missing information required for the dispensing and administration of the drug."

 

Sullivan et al., 1990
Noncompliance with medication regimens and subsequent hospitalizations

5.5% of admissions can be attributed to drug therapy noncompliance, amounting to 1.94 million admissions. This represents $8.5 billion in unnecessary hospital expenditures in 1986, an estimated 1.7% of all health care expenditures that year.

Drug therapy noncompliance—includes overuse, underuse, and erratic use of drugs.

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Raju et al., 1989
Medication errors in neonatal and paediatric intensivecare units

2,147 patients admitted to a 17-bed NICU and 7-bed PICU (1,224 to NICU [57%] and 923 to PICU [43%]) at the University of Illinois Hospital from January 1985 to December 1988.

Written incident reports submitted by the individual who noticed the error.

Blum et al., 1988
Medication error prevention by pharmacists

Orders written between November 1986 and February 1987 at Indiana University Hospitals that contained potential medication errors about which the physician had been contacted.

Carbon copies of orders saved by pharmacists in the pediatric and adult facilities and reviewed by the four co-authors that served as the study monitors.

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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Raju et al., 1989
Medication errors in neonatal and paediatric intensivecare units

315 iatrogenic medication errors were reported among the 2,147 neonatal and pediatric care admissions, an error rate of 1 per 6.8 admissions (14.7%). The frequency of iatrogenic injury of any sort due to a medication error was 3.1%, or 1 for each 33 intensive care admissions. 66 errors resulted in injury, 33 were potentially serious, 32 caused mild injuries, and 1 patient suffered acute aminophylline poisoning.

Medication error—"a dose of medication that deviates from the physicians' order as written in the medical record.... Except for error of omission, the medication dose must actually reach the patient ... a wrong dose (or other type of error) that is detected and corrected before administration will not constitute a medication error.... Prescription errors (not dispensed and administered to the patient) ... are excluded from this definition ..."

60.3% of the 315 errors were attributable to nurses and 29.6% to pharmacists. Only 2.9% were attributable to physicians (because prescription errors detected before drug administration were not counted).

Blum et al., 1988
Medication error prevention by pharmacists

123,367 medication orders were written. Riley Hospital for Children had 1,277 errors out of the 48,034 (2.7%) orders written and University Hospital had 1,012 errors out of 75,333 (1.3%) orders written. 90.4% of the overall orders questioned by pharmacists were confirmed by the physician as being in error. 0.2% of the 2289 errors were classified as potentially lethal, 13.7% were serious, 34.2% were significant, and 51.9% were minor. The number of errors that pharmacists prevent each year approaches 9,000.

Order with a potential medication error—"if any aspect of the order was not in accordance with information in standard reference text, an approved protocol, or dosing guidelines approved by the pharmacy and therapeutics committee of the hospitals."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Nolan and O'Malley, 1988 Prescribing for the elderly, part I

21 hospital inpatient studies conducted in the United States, United Kingdom, Israel, New Zealand, Switzerland, Canada, and India published between 1964 and 1981.

Review of published studies on adverse drug reactions (ADRs).

Folli et al., 1987
Medication error prevention by clinical pharmacists in two children's hospitals

101,022 medication orders prescribed in two children's teaching hospitals (Miller Children's Hospital of Memorial Medical Center [MMC] and Stanford University Medical Center [SUMC]) during a six-month period (February through July 1985).

Copies of errant chart orders reviewed by a member of the pediatric faculty or attending physician and by two pediatric clinical pharmacist practitioners.

Perlstein et al., 1979
Errors in drug computations during newborn intensive care

43 nursing, pharmacy, and medical personnel tested for accuracy in calculating drug doses to be administered to newborn infants. (27 registered nurses, 5 registered pharmacists, and 11 pediatricians.)

 

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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Nolan and O'Malley, 1988 Prescribing for the elderly, part I

Rates of patients experiencing ADRs ranged from 1.5% to 43.5%. A majority of the studies documented ADR rates between 10% and 25%.

   

Folli et al., 1987
Medication error prevention by clinical pharmacists in two children's hospitals

A combined total of 479 errant medication orders were identified at the two institutions. MMC and SUMC had similar frequency of error, 4.9 and 4.5 errors per 1,000 medication orders, or 1.37 and 1.79 per 100-patient days, respectively. Involving pharmacists in the reviewing of drug orders reduced the potential harm resulting from errant medication orders significantly.

Errant medication order—"An order was considered to be potentially in error if it was not in accordance with standard pediatric references, current published literature, or dosing guidelines approved by the pharmacy and therapeutics committees of each hospital."

The most common type of error was incorrect dosage. The most prevalent type of error was overdosage.

Perlstein et al., 1979
Errors in drug computations during newborn intensive care

The mean test score for nurses was 75.6%. 56% of the errors would have resulted in administered doses ten times greater or less than the ordered dose. The mean test score was 96% for pharmacists and none of the errors would have resulted in the administration of doses over 1% greater or less than the dose ordered. Pediatricians averaged a score of 89.1%. 38.5% of the errors would have resulted in the administration of doses ten times higher or lower than the dose ordered.

   

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Miller, 1977
Interpretation of studies on adverse drug reactions

 

Boston Collaborative Drug Surveillance Program

Burnum, 1976
Preventability of adverse drug reactions

1,000 adult medical patients drawn from a community, office-based practice of general internal medicine.

Physician observation.

Jick, 1974
Drugs: remarkably nontoxic

19,000 inpatients admitted to medical wards.

Boston Collaborative Drug Surveillance Program

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Miller, 1977
Interpretation of studies on adverse drug reactions

Adverse drug reactions (ADRs) occur in approximately 30% of hospitalized patients and after about 5% of drug exposures. The rate per patient of life-threatening ADRs in 3% and the rate per course of drug therapy is 0.4%.

   

Burnum, 1976
Preventability of adverse drug reactions

Adverse drug reactions (ADRs) occurred in 42 of the individual patients. 23 (55%) were judged unnecessary and potentially preventable.

 

23% of the 42 ADRs were attributable to physician error (10 out of 42; 6 because of giving a drug that was not indicated and 4 because of improper drug administration), 17% to patient or pharmacist error, and 14% to errors shared by the physician, patient and pharmacist.

Jick, 1974
Drugs: remarkably nontoxic

30% of hospitalized medical patients have at least 1 adverse drug reaction (ADR) while hospitalized. An estimated 3 million hospital patients have an ADR in medical units each year.

   

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Medication-related studies (continued)

   

Phillips et al., 1974
Increase in U.S. Medicationerror deaths between 1983 and 1993

 

All United States death certificates between 1983 and 1993.

Talley and Laventurier, 1974 Drug-induced illness

 

Boston Collaborative Drug Surveillance Program and an Israeli study.

Cost

   

Thomas et al., 1999

Medical records of 14,732 randomly selected 1992 discharges from 28 hospitals in Utah and Colorado

Two-stage chart review by trained nurses and board-certified family practitioners and internists.

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Reference

Results

Definition(s)

Causes/Types of Error

Medication-related studies (continued)

     

Phillips et al., 1974
Increase in U.S. Medicationerror deaths between 1983 and 1993

In 1983, 2,876 people died from medication errors. By 1993, this number had risen to 7,391, a 2.57-told increase. Between 1983 and 1993, outpatient medication error deaths rose 8.48-fold (from 172 to 1,459) and inpatient medical error deaths rose 2.37-fold (504 to 1,195).

Medication errors—
"'accidental poisoning by drugs, medicaments, and biologicals' and have resulted from acknowledged errors, by patients or medical personnel."

 

Talley and Laventurier, 1974 Drug-induced illness

An estimated incidence of lethal adverse drug reactions ranges from a low of 60,000 (.18% incidence) to a high of 140,000 (.44% incidence) for hospitalized patients in the U.S.

   

Cost

     

Thomas et al., 1999

459 adverse events were detected, of which 265 were preventable. Death occurred in 6.6% of adverse events and 6.9% of preventable adverse events. The total costs were $661,889,000 for adverse events and $308,382,000 for preventable adverse events.
Health care costs were $348,081,000 for all adverse events and $159,245,000 for preventable adverse events. 57% of the adverse event health care costs and 46% of the preventable adverse event costs were attributable to outpatient medical care.

Adverse event—"an injury caused by medical management (rather than the disease process) that resulted in either prolonged hospital stay or disability at time of discharge."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Cost (continued)

   

Bates et al., 1997
The costs of adverse drug events in hospitalized patients

4,108 admissions to a stratified random sample of 11 medical and surgical units in Brigham and Women's Hospital (726 beds) and Massachusetts General Hospital (846 beds) in Boston over a 6-month period between February and July 1993. Cases were patients with an adverse drug event (ADE), and the control for each case was a patient on the same unit as the case with the most similar pre-event length of stay.

Stimulated self-reports by nurses and pharmacists and daily chart review. 2 independent reviewers classified the incidents.

Bootman et al., 1997
The health care cost of drug-related morbidity and mortality in nursing facilities

To estimate the cost of drug-related problems (DRPs) within nursing facilities, a decision analysis technique was used to develop a probability pathway model.

Survey of an expert panel consisting of consultant pharmacists and physicians with practice experience in nursing facilities and geriatric care.

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Reference

Results

Definition(s)

Causes/Types of Error

Cost (continued)

     

Bates et al., 1997
The costs of adverse drug events in hospitalized patients

247 ADEs occurred among 207 admissions and 60 were preventable. The additional length of stay was 2.2 days with an ADE and 4.6 days with a preventable ADE. The estimated post-event costs attributable to an ADE were $2,595 for all ADEs and $4,685 for preventable ADEs. The estimated annual costs for a 700-bed teaching hospital attributable to all ADEs are $5.6 million and to preventable ADEs are $2.8 million. The national hospital costs of ADEs was estimated at $4 billion; preventable ADEs alone would cost $2 billion.

ADE—''an injury resulting from medical intervention related to a drug."
Potential ADE—"incidents in which an error was made but no harm occurred."

 

Bootman et al., 1997
The health care cost of drug-related morbidity and mortality in nursing facilities

The cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion compared with $7.6 billion without services of consultant pharmacists. For every dollar spent on drugs in nursing facilities, $1.33 is consumed in the treatment of DRPs.

DRPs—"an event of circumstance involving a patient's drug treatment that actually or potentially interferes with the achievement of an optimal outcome."

 

Continued

Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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TABLE C-1 Continued

Reference

Sample Description

Data Source

Cost (continued)

   

Johnson and Bootman, 1995
Drug-related morbidity and mortality

A probability pathway model was developed for drug-related morbidity and mortality based primarily on drug-related problems (DRPs). A panel of experts gave estimates on the numbers of patients affected by DRPs and monetary value data were taken from published reports and statistical reports.

Telephone survey of 15 expert practicing pharmacists.

Schneider et al., 1995
Cost of medication-related problems at a university hospital

109 patients at a universityaffiliated medical center hospital who were known to have had clinical consequences from an adverse drug reaction (ADR) or medication error.

Retrospective chart review.

Bloom, 1988
Cost of treating arthritis and NSAID-related gastrointestinal side-effects

Retrospective analysis of all direct costs related to the care of 527 Medicaid recipients treated for arthritis with non-steroidal anti-inflammatory drugs (NSAIDs) between December 1,1981 and November 30, 1983.

Medicaid Management Information System of Washington, D.C.

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Suggested Citation:"C Literature Summary." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Reference

Results

Definition(s)

Causes/Types of Error

Cost (continued)

     

Johnson and Bootman, 1995
Drug-related morbidity and mortality

Drug-related morbidity and mortality costs an estimated $76.6 billion in the ambulatory setting in the United States. The panel members estimated that 40% of patients who receive drug therapy would have some form of DRP.

Drug-related problem—"an event or circumstance that involves a patient's drug treatment that actually, or potentially, interferes with the achievement of an optimal outcome."

 

Schneider et al., 1995
Cost of medication-related problems at a university hospital

349 clinical outcomes associated with medical related problems (MRPs) (average of approximately 3 outcomes per patient) were detected. For the 1,911 ADRs and medication errors reported through the voluntary reporting system in 1994, the estimated annual cost was just under $1.5 million.

   

Bloom, 1988
Cost of treating arthritis and NSAID-related gastrointestinal side-effects

In 1983, an estimated $3.9 million was spent on treating preventable gastrointestinal adverse drug reactions to NSAIDs.

Gastrointestinal adverse drug reaction—"any claim for payment accompanied by a diagnosis of peptic ulcer, gastritis/duodenitis, other disorders of the stomach or duodenum, gastrointestinal symptoms, or a pharmacy claim for an H2-recepter antagonist, sucralfate or antacid, which occurred during the arthritis treatment study period.

 
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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