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Outpatient medication errors common, difficult to detect among transplant patients
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Medication errors appear to be common, often hidden and associated with adverse events among patients receiving out patient care after an organ transplant, according to a report in the March issue of Archives of Surgery, one of the JAMA/Archives journals. The health care system is involved with nearly one-third of these errors.

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Medication use is increasingly common—more than 60 percent of U.S. adults aged 45 to 64 reported using at least one prescription drug during the previous month when surveyed from 1999 to 2000, according to background information in the article. Medication errors are common as well, with adverse drug events reported among 6.5 percent of hospitalized patients. “It seems logical that the additional degrees of freedom introduced in the outpatient setting by the patient, caretaker, outside pharmacy or third-party payer will result in greater confusion and error,” the authors write. “Examples of the types of serious errors anecdotally reported to date in this setting include mix-ups between sound-alike and look-alike drugs, similar looking packaging and inappropriate dosing.”

Amy L. Friedman, M.D., and colleagues at the Yale University School of Medicine, New Haven, connecticut, documented medication errors that occurred among all recipients of liver, kidney and pancreas transplants who were tracked by the Yale New Haven Organ Transplantation Center between April 1, 2004, and March 31, 2005. “At every encounter, the home medication regimen is reviewed with the patient by a nurse-coordinator, physician associate or physician and compared with the regimen prescribed at the last interaction with the patient,” the authors write. Encounters include outpatient or emergency department visits, admission to the hospital or phone conversations.

During the study period, the researchers identified 149 medication errors in 93 patients, who were taking an average of 10.9 medications each. The most frequent type of error (56 percent of all errors) was patient error. An additional 13 percent of the errors were prescription errors; 13 percent were delivery errors; 10 percent were availability errors, when a patient did not have at least a 24-hour supply of a medication; and 8 percent were reporting errors, which occurred when a patient could not give the researchers enough information to identify the type, dosage, or frequency of a medication. Adverse events were associated with 48 (32 percent) of the errors, including 17 hospitalizations, three outpatient procedures, nine episodes of rejection and six failed transplants.

The researchers also pinpointed the root causes of the errors. “The root cause was defined as a specific underlying cause that can reasonably be identified, that is in the control of the transplant team to fix and for which effective recommendations for preventing recurrences could be generated,” the authors write. The root causes were identified as the patient in 68 percent of the errors, financial issues in 5 percent and health care providers in 27 percent, including 10 percent caused by the transplant team itself.

Understanding the root causes of medication errors, which often stem from communication failures, should help remove the judgmental lens through which non-adherence to drug therapies is often viewed, the authors conclude. “We should strive to continue to eliminate health care system–based errors through centralized records and other streamlining methods to improve processes. In doing so, it seems likely that our patients will gain confidence in us and our ability to help them navigate a complex and confusing system.” This will both improve patient safety and facilitate the shift from a culture of blame to a culture of prevention, they note.
(Arch Surg. 2007;142:278-283. Available to the media pre-embargo at

Editor's Note: This research was funded under a grant from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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