October 2001

From University of Pennsylvania Medical Center

Reducing the risk of medication errors: Announcing the Penn Center for Patient Safety Research and Practice

(Philadelphia, PA) – The University of Pennsylvania Medical Center has assembled a multidisciplinary team of physicians and researchers to form the Center of Excellence for Patient Safety Research and Practice. A $7 million grant from the Agency for Healthcare Research and Quality (AHRQ) will fund the center through its first five years of operation. The center’s mission will be to examine medication errors and address practical ways to prevent their often-fatal effects.

"Sadly, medication errors are among the most common – and potentially preventable – types of medical errors," said Brian L. Strom, MD, MPH, director of the new center and chair of the Penn Department of Biostatistics and Epidemiology. "They account for more deaths each year than motor vehicle accidents, breast cancer, or HIV infection – at an annual cost of $17 to $29 billion."

Of course, much is already known about medication errors. The elderly are most often at risk for such complications. Anticonvulsants are among the high-risk drugs. So are digoxin (also known as Lanoxin), used to treat congestive heart failure, and anticoagulants, such as warfarin (also known as Coumadin). The most common effects of medication errors are internal bleeding and kidney failure.

There are many causes of medication errors, and they can occur anywhere in the medication use process, including diagnosis, prescribing, dispensing, administering, ingesting, and monitoring. Among healthcare professionals, factors such as work stress, distractions, interruptions, inadequate training, fragmented information, or information overload may increase the risk of committing errors in the handling and monitoring of drugs.

Moreover, medication errors are also a societal issue. Patients often cannot – or do not – adhere to prescribed drug regimens, an error that accounts for almost a quarter of all hospital admissions attributed to drugs. Poor adherence can take the form of overuse, under-use, or erratic use of the drug. Among patients, factors such as advanced age, frailty, cultural or literacy barriers, mental illness or incapacity, or lack of adequate social support have all been found to contribute to the inability to adhere to prescribed drug regimens.

"Clearly, there is no single cause for this problem – and no single solution, either," said Strom. "But it is a problem that can be solved, and this center brings together researchers that will address both the clinical and societal issues behind medication errors."

Indeed, the center’s investigators hail a host of different backgrounds, including pharmaceutical epidemiology, health services research, biostatistics, occupational medicine, sociology, psychology, and economics. They will be drawing on Penn’s 20 years of experience in studying medication safety problems to conduct multidisciplinary research and education programs designed to identify and implement systematic approaches to reducing errors. The AHRQ grant is also recognition of the success and prominence of the Hospital of the University of Pennsylvania’s Drug Use and Effects Program in to reduce medication errors.

The center has already designed four inaugural projects that attack the problem of medication errors in real-world clinical settings. The projects are based at Penn and linked to the government of the Commonwealth of Pennsylvania as well as a national network of medication education and research centers.

The first project investigates factors that may predispose elderly patients to hospitalizations due to errors in medication use. For this project, collaboration with a state-run, population-based pharmaceutical benefit program will greatly enhance the ability to widely examine dose-related medication errors among elderly individuals taking specific high-risk drugs. This project should help create a prediction rule to identify and decrease medication errors in high-risk patients that result in hospitalization.

The second project tackles error from the direction of adherence, researching indicators that predict poor adherence to warfarin therapy in an anticoagulation clinic. Outcomes from this project should help develop a predictive index that will allow healthcare workers to identify which patients are at risk for medication errors before they begin therapy.

The third project studies medication errors as the cause of preventable kidney failure among hospital inpatients. The researchers will examine the preexisting pharmaceutical monitoring system and determine how the system can be improved to decrease medication errors.

The fourth project examines the sociological and organizational causes of medication errors at the clinical level. The center will study the extent to which workplace conditions lead to medication errors among physicians, with emphasis on stress-inducing conditions, such as workload, schedules, work organization, shifts, and patient/staff ratios. Results could help design systems that decrease stress on health professionals and in turn, decrease prescription error rates. "We have our work cut out for us, but this is not an impossible mission," said Strom. "The ultimate goal of this center is to determine practical methods to decrease these errors in order to improve patient health and lower medical costs."












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