Preventable adverse drug events causing hospitalization: Identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study de Lemos, Jane; Loewen, Peter; Zed, Peter; Nagle, Cheryl; McKenzie, Robert; You, Yong Dong; Dabu, Anna; Ling, Peter; Chan, Richard
Background: To identify root causes of preventable adverse drug events contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community. Methods: Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported. Results: Most common pADE-related medical conditions: Chronic obstructive pulmonary disease (COPD)/asthma (13.5%) bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%), pneumonia (5%). Most common root causes were: providers not confirming that patient/family: understands information given (29.2%), how a medication helps them/addressing concerns (16.7%), how to identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%), absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented. Interpretation: To prevent pADEs providers need to confirm that patients/families understand: information given, how a medication helps them, how to recognize and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient’s/families’ medication use and monitoring competency.