Prevention of Drug-Related Complications. Appendix, Executive Summary and FinalReport

摘要

The study measured the frequency, costs, preventability, and underlying systemsfailures resulting in adverse drug events during a six month period in 12 units in two teaching hospitals. An adverse drug event (ADE) is an injury related to use of a drug. Hosiptal rates were 6.5 ADEs and 5.5 potential ADEs per 100 admissions. Twenty-eight percent of ADEs and all potential ADEs were preventable. The authors estimate the total number of preventable events for a 750 bed teaching hospital is 2100. The cost differential for a patient with an ADE is $8000, or $15,000,000 per year per hospital. Errors were most common in the physician ordering stage, and most often resulted from lack of knowledge of the drug. Sixteen major systems failures were identified as underlying the errors.