Medication‐related adverse events during hospitalization: a retrospective patient record review study in The Netherlands

Damen, Nikki L.; Baines, Rebecca J; Wagner, Cordula; Langelaan, Maaike

doi:10.1002/pds.4037

Cited by 18 publications

(14 citation statements)

References 35 publications

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“…In general, anticoagulants are consistently identified in adverse event studies as factors involved in preventable adverse events [8, 9], partially occurring in the context of bridging [10].…”

Section: Introductionmentioning

confidence: 99%

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

et al. 2019

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Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69–81.99), vascular surgery (OR 13.01, 95% CI 1.83–92.30), non-elective surgery (OR 8.67, 95% CI 1.67–45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11–1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04–1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients. Electronic supplementary material The online version of this article (10.1186/s12959-019-0204-x) contains supplementary material, which is available to authorized users.

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Section: Introductionmentioning

confidence: 99%

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

et al. 2019

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“…More recently, some comparative longitudinal studies within the same group of hospitals have been published [ 5 – 9 ], comparing AEs between countries [ 10 ], evaluating the costs associated with AEs [ 11 , 12 ]; analysing the reliability of the research methods based on medical record reviews [ 13 – 15 ], and making comparisons of AEs between hospitals and departments [ 9 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

Patient and hospital characteristics that influence incidence of adverse events in acute public hospitals in Portugal: a retrospective cohort study

Sousa

Uva

Serranheira

et al. 2018

International Journal for Quality in Health Care

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ObjectiveTo analyse the variation in the rate of adverse events (AEs) between acute hospitals and explore the extent to which some patients and hospital characteristics influence the differences in the rates of AEs.DesignRetrospective cohort study. Chi-square test for independence and binary logistic regression models were used to identify the potential association of some patients and hospital characteristics with AEs.SettingNine acute Portuguese public hospital centres.ParticipantsA random sample of 4250 charts, representative of around 180 000 hospital admissions in 2013, was analysed.InterventionTo measure adverse events based on chart review.Main Outcome MeasureRate of AEs.ResultsMain results: (i) AE incidence was 12.5%; (ii) 66.4% of all AEs were related to Hospital-Acquired Infection and surgical procedures; (iii) patient characteristics such as sex (female 11%; male 14.4%), age (≥65 y 16.4%; <65 y 8.5%), admission coded as elective vs. urgent (8.6% vs. 14.6%) and medical vs. surgical Diagnosis Related Group code (13.4% vs. 11.7%), all with p < 0.001, were associated with a greater occurrence of AEs. (iv) hospital characteristics such as use of reporting system (13.2% vs. 7.1%), being accredited (13.7% vs. non-accredited 11.2%), university status (15.9% vs. non-university 10.9%) and hospital size (small 12.9%; medium 9.3%; large 14.3%), all with p < 0.001, seem to be associated with a higher rate of AEs.ConclusionsWe identified some patient and hospital characteristics that might influence the rate of AEs. Based on these results, more adequate solutions to improve patient safety can be defined.

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“…High-risk situations, polypharmacy and transitions of care have been identified as three key areas to be addressed by health care organisations to protect patients from adverse medication events and subsequent harm (WHO, 2017). Resident age, number of medications, multi co-morbidity and staff competence are other factors impacting on safe medication administration (Panagioti et al, 2015;Damen et al, 2017;Ryan et al, 2014).…”

Section: Resultsmentioning

confidence: 99%

To err is human: medication patient safety in aged care, a case study

Gilbert

Kim

2018

QAOA

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Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

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Medication‐related adverse events during hospitalization: a retrospective patient record review study in The Netherlands

Cited by 18 publications

References 35 publications

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Patient and hospital characteristics that influence incidence of adverse events in acute public hospitals in Portugal: a retrospective cohort study

To err is human: medication patient safety in aged care, a case study

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