Medication errors common in transplant recipients
Last Updated: 2007-04-04 15:59:41 -0400 (Reuters Health)
By David Douglas
NEW YORK (Reuters Health) - A study of patients who received liver, kidney or pancreas transplants shows that many experienced medication errors, and a number of these errors led to adverse events.
"Healthcare providers should understand that the medications they prescribe are often not taken or used as they were intended," lead researcher Dr. Amy L. Friedman told Reuters Health. "Patients unintentionally make the majority of these errors, but the healthcare system itself is responsible for nearly one third," she said.
To investigate the factors underlying these errors, Friedman, of Yale University School of Medicine, New Haven, Connecticut, and colleagues reviewed data on the expected and actual medications taken by a group of transplant recipients. The findings are reported in the Archives of Surgery.
The physicians identified 149 errors in 93 patients who were each prescribed an average of 11 drugs. The errors included failure to provide a correct prescription; failure to deliver a correct prescription; not providing enough medication in a timely fashion; and patients not taking the drugs correctly.
Adverse events were the results of 48 errors. These included hospitalization in 17 patients and invasive procedures performed outside the hospital in 13 percent.
Nine episodes of organ rejection and six organ failures were identified. Half of these were due to medication availability errors.
Overall, patient errors were the most common (56 percent). However, 13 percent were prescription errors, 13 percent were delivery errors, and the rest were drug availability and reporting errors.
Additional analysis identified the patient as the cause in 101 errors (68 percent) and pharmacies and other sectors of the health care team as the cause of 41 errors (27 percent). Financial factors were associated with 7 errors (5 percent).
Given these findings, Friedman conclude that "patients should be asked to report exactly which medications they are taking, so that otherwise unsuspected differences between what is prescribed and what is taken can be recognized." This may help prevent dangerous, and sometimes undetectable, consequences for the patient.
SOURCE: Archives of Surgery, March 2007.
