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March 4 2003 — More than a quarter of adverse drug events among older persons in outpatient settings could be considered preventable, according to a study in the March 5 issue of The Journal of the American Medical Association. A recent national survey of the adult population in the United States (not living in nursing homes or other institutions) indicated that more than 90 percent of persons aged 65 years or older used at least one medication per week, the authors provide as background information in the article. More than 40 percent used five or more different medications each week, and 12 percent used 10 or more different medications per week.
Jerry H. Gurwitz, M.D., from University of Massachusetts Medical School, Worcester, Mass., and colleagues assessed the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting, i.e., office or clinic settings. Adverse drug events are defined by the authors as an injury resulting from the use of a drug. Adverse drug events were categorized as significant, serious, life-threatening or fatal.
"Adverse drug events may have resulted from medication errors (i.e., errors in prescribing, dispensing, patient adherence and monitoring) or from adverse drug reactions in which there was no error," the authors write. "Adverse drug events were considered to be preventable if they were due to an error and were preventable by any means available."
The researchers conducted a study of 27,617 Medicare enrollees aged 65 years and older, cared for by a multi-specialty group practice in a New England-based health maintenance organization during a one-year period. Drug-related incidents were detected by reports from healthcare professionals; reviews of hospital discharge summaries, emergency department notes, electronic clinic notes, and administrative incident reports; and computerized searching for combinations of drugs prescribed and common adverse events.
"There were 1,523 identified adverse drug events, of which 27.6 percent (421) were considered preventable," the authors report. "The overall rate of adverse drug events was 50.1 per 1,000 person-years, with a rate of 13.8 preventable adverse drug events per 1,000 person years. Of the adverse drug events, 578 (38 percent) were categorized as serious, life-threatening or fatal; 244 (42.2 percent) of these more severe events were deemed preventable, compared with 177 (18.7 percent) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n=246, 58.4 percent) and monitoring (n=256, 60.8 percent), and errors involving patient adherence (n=89, 21.1 percent) also were common," the authors note.
The authors state that the most common medication categories associated with preventable adverse drug events include cardiovascular agents, diuretics, antibiotics, nonopioid analgesics and anticoagulants. "Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial," the authors conclude.
Classen states that interventions to reduce ADEs need to be implemented. "... several interventions effective at reducing medication errors in the inpatient setting could be generalized to the outpatient setting. These include computerized physician order entry of medications with decision support (i.e., drug interaction checking, allergy checking, dose and frequency adjusting, and treatment duration limits), clinical pharmacist consultation services, and clinics for anticoagulation therapy."
"The study by Gurwitz et al has helped to provide a clearer view of the illusion of medication safety this time in the outpatient arena. When their work is combined with other studies, medications still pose a significant risk to patients across the continuum of care despite decades of research and advances in drug therapy. Although the potential exists to reduce this risk markedly with existing interventions, lack of progress in this area is compounded by the increasing complexity of drug therapies and the increasing vulnerability of those who receive them," Classen concludes.