Identifying Medication Misadventures: Poor Agreement Among Medical Record, Physician, Nurse, and Patient Reports

• DOI: 10.1592/phco.30.5.529
• Publication Date: 2010-04-23T11:22:41Z
• Authors: Peter J. Kaboli; Justin M. Glasgow; C. Komal Jaipaul; William A. Barry; Jill R. Strayer; Barbara Mutnick; Gary E. Rosenthal
• Keywords: Medical record; Electronic medical record; Electronic health record

To analyze and compare four different methods of detecting medication misadventures in order to determine the optimal system for reporting clinically observed misadventures.Prospective cohort study.Forty-eight-bed general internal medicine inpatient ward at a large academic teaching hospital with decentralized pharmacy system.One hundred twenty-six patients (54% male, mean age 54 yrs) 133 consecutive admissions (mean length stay 7.8 days) over an 8-week period from December 2001-February 2002.Medication were detected by methods: house staff (resident physicians) report during their morning conference, nursing shift change, patient discharge interview, standardized medical record review. All compared hospital's existing electronic misadventure system.Overall, 63 (47% admissions) experienced least one misadventure. Thirty-seven adverse drug events (ADEs) 69 errors 1035 bed-days. Little overlap was noted among intervention methods, nearly 80% all 106 only single method (medical review 51% [54 events], interview 11% [12], house-staff 9% [10], nurse 8% [9]). Of 37 ADEs, 6 (16%) due 10 (27%) preventable. five life-threatening preventable, reported system; however, two nurse, resident physician, patient.Little individual suggesting need use multiple complementary identify hospitalized patients. These findings have important implications development surveillance systems, design prevention initiatives, future safety research.