Tejal K. Gandhi, M.D., M.P.H., Saul N. Weingart, M.D., Ph.D., Joshua Borus, B.A., Andrew C. Seger, R.Ph., Josh Peterson, M.D., Elisabeth Burdick, M.S., Diane L. Seger, R.Ph., Kirstin Shu, B.A., Frank Federico, R.Ph., Lucian L. Leape, M.D., and David W. Bates, M.D.
Background Adverse events related to drugs occur frequentlyamong inpatients, and many of these events are preventable.However, few data are available on adverse drug events amongoutpatients. We conducted a study to determine the rates, types,severity, and preventability of such events among outpatientsand to identify preventive strategies.
Methods We performed a prospective cohort study, including asurvey of patients and a chart review, at four adult primarycare practices in Boston (two hospital-based and two community-based),involving a total of 1202 outpatients who received at leastone prescription during a four-week period. Prescriptions werecomputerized at two of the practices and handwritten at theother two.
Conclusions Adverse events related to drugs are common in primarycare, and many are preventable or ameliorable. Monitoring forand acting on symptoms are important. Improving communicationbetween outpatients and providers may help prevent adverse eventsrelated to drugs.
Source Information
From the Division of General Internal Medicine, Brigham and Women's Hospital (T.K.G., J.B., A.C.S., J.P., E.B., D.L.S., K.S., D.W.B.); the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center (S.N.W.); the Harvard Risk Management Foundation (F.F.); and the Harvard School of Public Health (L.L.L.) — all in Boston.
Address reprint requests to Dr. Gandhi at the Division of General Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, or at tgandhi{at}partners.org.
Volmer, D., Maesalu, M., Bell, J. S.
(2008). Pharmacy Students' Attitudes Toward and Professional Interactions With People With Mental Disorders. Int J Soc Psychiatry
54: 402-413
[Abstract]
Carter, B. L., Farris, K. B., Abramowitz, P. W., Weetman, D. B., Kaboli, P. J., Dawson, J. D., James, P. A., Christensen, A. J., Brooks, J. M.
(2008). The Iowa Continuity of Care study: Background and methods. Am J Health Syst Pharm
65: 1631-1642
[Abstract][Full Text]
Kennedy, A. G., Littenberg, B., Senders, J. W.
(2008). Using nurses and office staff to report prescribing errors in primary care. Int J Qual Health Care
20: 238-245
[Abstract][Full Text]
Phillips, D. P., Barker, G. E. C., Eguchi, M. M.
(2008). A Steep Increase in Domestic Fatal Medication Errors With Use of Alcohol and/or Street Drugs. Arch Intern Med
168: 1561-1566
[Abstract][Full Text]
Weissman, J. S., Schneider, E. C., Weingart, S. N., Epstein, A. M., David-Kasdan, J., Feibelmann, S., Annas, C. L., Ridley, N., Kirle, L., Gatsonis, C.
(2008). Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not?. ANN INTERN MED
149: 100-108
[Abstract][Full Text]
Tamblyn, R., Huang, A., Taylor, L., Kawasumi, Y., Bartlett, G., Grad, R., Jacques, A., Dawes, M., Abrahamowicz, M., Perreault, R., Winslade, N., Poissant, L., Pinsonneault, A.
(2008). A Randomized Trial of the Effectiveness of On-demand versus Computer-triggered Drug Decision Support in Primary Care. J. Am. Med. Inform. Assoc.
15: 430-438
[Abstract][Full Text]
Brown, C, Hofer, T, Johal, A, Thomson, R, Nicholl, J, Franklin, B D, Lilford, R J
(2008). An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement. Qual Saf Health Care
17: 170-177
[Abstract][Full Text]
Graham, D G, Harris, D M, Elder, N C, Emsermann, C B, Brandt, E, Staton, E W, Hickner, J
(2008). Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network. Qual Saf Health Care
17: 201-208
[Abstract][Full Text]
Hogan, H, Olsen, S, Scobie, S, Chapman, E, Sachs, R, McKee, M, Vincent, C, Thomson, R
(2008). What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?. Qual Saf Health Care
17: 209-215
[Abstract][Full Text]
Tam, K. W. T., Kwok, H. K., Fan, Y. M. C., Tsui, K. B., Ng, K. K., Ho, K. Y. A., Lau, K. T., Chan, Y. C., Tse, C. W. C., Lau, C. M.
(2008). Detection and prevention of medication misadventures in general practice. Int J Qual Health Care
20: 192-199
[Abstract][Full Text]
Howard, R, Avery, A, Bissell, P
(2008). Causes of preventable drug-related hospital admissions: a qualitative study. Qual Saf Health Care
17: 109-116
[Abstract][Full Text]
Oladimeji, O., Farris, K. B, Urmie, J. G, Doucette, W. R
(2008). Risk Factors for Self-Reported Adverse Drug Events Among Medicare Enrollees. The Annals of Pharmacotherapy
42: 53-61
[Abstract][Full Text]
Budnitz, D. S., Shehab, N., Kegler, S. R., Richards, C. L.
(2007). Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults. ANN INTERN MED
147: 755-765
[Abstract][Full Text]
Moore, C., Lin, J., McGinn, T., Halm, E.
(2007). Factors Associated with Time to Follow-up of Severe Hyperkalemia in the Ambulatory Setting. American Journal of Medical Quality
22: 428-437
[Abstract]
Dallenbach, M.F., Bovier, P.A., Desmeules, J.
(2007). Detecting drug interactions using personal digital assistants in an out-patient clinic. QJM
100: 691-697
[Abstract][Full Text]
Boyd, C. M., Boult, C., Shadmi, E., Leff, B., Brager, R., Dunbar, L., Wolff, J. L., Wegener, S.
(2007). Guided Care for Multimorbid Older Adults: Kathleen Walsh Piercy, PhD, Editor. Gerontologist
47: 697-704
[Abstract][Full Text]
Cresswell, K. M., Fernando, B., McKinstry, B., Sheikh, A.
(2007). Adverse drug events in the elderly. Br Med Bull
83: 259-274
[Abstract][Full Text]
Thomsen, L. A., Winterstein, A. G, Sondergaard, B., Haugbolle, L. S., Melander, A.
(2007). Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory Care. The Annals of Pharmacotherapy
41: 1411-1426
[Abstract][Full Text]
Moskowitz, E. J., Nash, D. B.
(2007). The Quality and Safety of Ambulatory Medical Care: Current and Future Prospects. American Journal of Medical Quality
22: 274-288
Eslami, S., Abu-Hanna, A., de Keizer, N. F.
(2007). Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review. J. Am. Med. Inform. Assoc.
14: 400-406
[Abstract][Full Text]
Glassman, P. A., Belperio, P., Lanto, A., Simon, B., Valuck, R., Sayers, J., Lee, M.
(2007). The Utility of Adding Retrospective Medication Profiling to Computerized Provider Order Entry in an Ambulatory Care Population. J. Am. Med. Inform. Assoc.
14: 424-431
[Abstract][Full Text]
Raebel, M. A., Carroll, N. M., Kelleher, J. A., Chester, E. A., Berga, S., Magid, D. J.
(2007). Randomized Trial to Improve Prescribing Safety During Pregnancy. J. Am. Med. Inform. Assoc.
14: 440-450
[Abstract][Full Text]
Council on Clinical Information Technology,
(2007). Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements. Pediatrics
119: 1229-1231
[Abstract][Full Text]
Gerstle, R. S., Lehmann, C. U., the Council on Clinical Information Technology,
(2007). Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements. Pediatrics
119: e1413-e1422
[Abstract][Full Text]
Katzan, I. L., Dawson, N. V., Thomas, C. L., Votruba, M. E., Cebul, R. D.
(2007). The cost of pneumonia after acute stroke. Neurology
68: 1938-1943
[Abstract][Full Text]
Shrank, W., Avorn, J., Rolon, C., Shekelle, P.
(2007). Effect of Content and Format of Prescription Drug Labels on Readability, Understanding, and Medication Use: A Systematic Review. The Annals of Pharmacotherapy
41: 783-801
[Abstract][Full Text]
Woods, D. M, Thomas, E. J, Holl, J. L, Weiss, K. B, Brennan, T. A
(2007). Ambulatory care adverse events and preventable adverse events leading to a hospital admission. Qual Saf Health Care
16: 127-131
[Abstract][Full Text]
(2007). Medical Errors: Focusing More on What and Why, Less on Who. J Oncol Pract
3: 66-70
[Full Text]
Van Vorst, R. F., Araya-Guerra, R., Felzien, M., Fernald, D., Elder, N., Duclos, C., Westfall, J. M.
(2007). Rural Community Members' Perceptions of Harm from Medical Mistakes: A High Plains Research Network (HPRN) Study. J Am Board Fam Med
20: 135-143
[Abstract][Full Text]
Kuo, G. M., Mullen, P. D., McQueen, A., Swank, P. R., Rogers, J. C.
(2007). Cross-Sectional Comparison of Electronic and Paper Medical Records on Medication Counseling in Primary Care Clinics: A Southern Primary-care Urban Research Network (SPUR-Net) Study. J Am Board Fam Med
20: 164-173
[Abstract][Full Text]
Friedman, A. L., Geoghegan, S. R., Sowers, N. M., Kulkarni, S., Formica, R. N. Jr
(2007). Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis. Arch Surg
142: 278-283
[Abstract][Full Text]
Kramer, J. S., Hopkins, P. J., Rosendale, J. C., Garrelts, J. C., Hale, L. S., Nester, T. M., Cochran, P., Eidem, L. A., Haneke, R. D.
(2007). Implementation of an electronic system for medication reconciliation. Am J Health Syst Pharm
64: 404-422
[Abstract][Full Text]
Parnes, B., Fernald, D., Quintela, J., Araya-Guerra, R., Westfall, J., Harris, D., Pace, W.
(2007). Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care
16: 12-16
[Abstract][Full Text]
Kuperman, G. J., Bobb, A., Payne, T. H., Avery, A. J., Gandhi, T. K., Burns, G., Classen, D. C., Bates, D. W.
(2007). Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review. J. Am. Med. Inform. Assoc.
14: 29-40
[Abstract][Full Text]
Davis, T. C., Wolf, M. S., Bass, P. F. III, Thompson, J. A., Tilson, H. H., Neuberger, M., Parker, R. M.
(2006). Literacy and Misunderstanding Prescription Drug Labels. ANN INTERN MED
145: 887-894
[Abstract][Full Text]
Johnston, P. E., France, D. J., Byrne, D. W., Murff, H. J., Lee, B., Stiles, R. A., Speroff, T.
(2006). Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm
63: 2218-2227
[Abstract][Full Text]
Budnitz, D. S., Pollock, D. A., Weidenbach, K. N., Mendelsohn, A. B., Schroeder, T. J., Annest, J. L.
(2006). National surveillance of emergency department visits for outpatient adverse drug events.. JAMA
296: 1858-1866
[Abstract][Full Text]
Wachter, R. M.
(2006). Is ambulatory patient safety just like hospital safety, only without the "stat"?. ANN INTERN MED
145: 547-549
[Full Text]
Poon, E. G., Cina, J. L., Churchill, W., Patel, N., Featherstone, E., Rothschild, J. M., Keohane, C. A., Whittemore, A. D., Bates, D. W., Gandhi, T. K.
(2006). Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy.. ANN INTERN MED
145: 426-434
[Abstract][Full Text]
Hildebrandt, D. E., Westfall, J. M., Fernald, D. H., Pace, W. D.
(2006). Harm Resulting from Inappropriate Telephone Triage in Primary Care. J Am Board Fam Med
19: 437-442
[Abstract][Full Text]
Linder, J. A., Chan, J. C., Bates, D. W.
(2006). Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic.. Arch Intern Med
166: 1374-1379
[Abstract][Full Text]
Lin, J. J., Dunn, A., Moore, C.
(2006). Follow-up of Outpatient Test Results: A Survey of House-Staff Practices and Perceptions.. American Journal of Medical Quality
21: 178-184
[Abstract]
Hanlon, J. T., Pieper, C. F., Hajjar, E. R., Sloane, R. J., Lindblad, C. I., Ruby, C. M., Schmader, K. E.
(2006). Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay.. J. Gerontol. A Biol. Sci. Med. Sci.
61: 511-515
[Abstract][Full Text]
Shojania, K. G.
(2006). Safe medication prescribing and monitoring in the outpatient setting.. CMAJ
174: 1257-1258
[Full Text]
Dunham, D. P., Baker, D.
(2006). Use of an electronic medical record to detect patients at high risk of metformin-induced lactic acidosis. Am J Health Syst Pharm
63: 657-660
[Abstract][Full Text]
Weingart, S. N., Pagovich, O., Sands, D. Z., Li, J. M., Aronson, M. D., Davis, R. B., Phillips, R. S., Bates, D. W.
(2006). Patient-reported service quality on a medicine unit. Int J Qual Health Care
18: 95-101
[Abstract][Full Text]
Schnipper, J. L., Kirwin, J. L., Cotugno, M. C., Wahlstrom, S. A., Brown, B. A., Tarvin, E., Kachalia, A., Horng, M., Roy, C. L., McKean, S. C., Bates, D. W.
(2006). Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization.. Arch Intern Med
166: 565-571
[Abstract][Full Text]
Moore, C. R., Lin, J. J., O'Connor, N., Halm, E. A.
(2006). Follow-up of Markedly Elevated Serum Potassium Results in the Ambulatory Setting: Implications for Patient Safety.. American Journal of Medical Quality
21: 115-124
[Abstract]
Tamblyn, R., Huang, A., Kawasumi, Y., Bartlett, G., Grad, R., Jacques, A., Dawes, M., Abrahamowicz, M., Perreault, R., Taylor, L., Winslade, N., Poissant, L., Pinsonneault, A.
(2006). The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care. J. Am. Med. Inform. Assoc.
13: 148-159
[Abstract][Full Text]
Tang, P. C., Ash, J. S., Bates, D. W., Overhage, J. M., Sands, D. Z.
(2006). Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. J. Am. Med. Inform. Assoc.
13: 121-126
[Abstract][Full Text]
Lasser, K. E., Seger, D. L., Yu, D. T., Karson, A. S., Fiskio, J. M., Seger, A. C., Shah, N. R., Gandhi, T. K., Rothschild, J. M., Bates, D. W.
(2006). Adherence to black box warnings for prescription medications in outpatients.. Arch Intern Med
166: 338-344
[Abstract][Full Text]
Royal, S, Smeaton, L, Avery, A J, Hurwitz, B, Sheikh, A
(2006). Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Qual Saf Health Care
15: 23-31
[Abstract][Full Text]
Espino, D. V., Bazaldua, O. V., Palmer, R. F., Mouton, C. P., Parchman, M. L., Miles, T. P., Markides, K.
(2006). Suboptimal Medication Use and Mortality in an Older Adult Community-Based Cohort: Results From the Hispanic EPESE Study.. J. Gerontol. A Biol. Sci. Med. Sci.
61: 170-175
[Abstract][Full Text]
Hansen, L. B., Fernald, D., Araya-Guerra, R., Westfall, J. M., West, D., Pace, W.
(2006). Pharmacy Clarification of Prescriptions Ordered in Primary Care: A Report from the Applied Strategies for Improving Patient Safety (ASIPS) Collaborative. J Am Board Fam Med
19: 24-30
[Abstract][Full Text]
Linder, J. A., Bates, D. W., Williams, D. H., Connolly, M. A., Middleton, B.
(2006). Acute Infections in Primary Care: Accuracy of Electronic Diagnoses and Electronic Antibiotic Prescribing. J. Am. Med. Inform. Assoc.
13: 61-66
[Abstract][Full Text]
Alexander, K. P., Chen, A. Y., Roe, M. T., Newby, L. K., Gibson, C. M., Allen-LaPointe, N. M., Pollack, C., Gibler, W. B., Ohman, E. M., Peterson, E. D., for the CRUSADE Investigators,
(2005). Excess Dosing of Antiplatelet and Antithrombin Agents in the Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes. JAMA
294: 3108-3116
[Abstract][Full Text]
Linder, J. A., Bates, D. W., Lee, G. M., Finkelstein, J. A.
(2005). Antibiotic Treatment of Children With Sore Throat. JAMA
294: 2315-2322
[Abstract][Full Text]
Masoudi, F. A., Baillie, C. A., Wang, Y., Bradford, W. D., Steiner, J. F., Havranek, E. P., Foody, J. M., Krumholz, H. M.
(2005). The Complexity and Cost of Drug Regimens of Older Patients Hospitalized With Heart Failure in the United States, 1998-2001. Arch Intern Med
165: 2069-2076
[Abstract][Full Text]
Zed, P. J.
(2005). Drug-Related Visits to the Emergency Department. Journal of Pharmacy Practice
18: 329-335
[Abstract]
Teich, J. M., Osheroff, J. A., Pifer, E. A., Sittig, D. F., Jenders, R. A., the CDS Expert Review Panel,
(2005). Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan: Report of the Joint Clinical Decision Support Workgroup. J. Am. Med. Inform. Assoc.
12: 365-376
[Abstract][Full Text]
Elwood, P., Morgan, G., Brown, G., Pickering, J.
(2005). Aspirin for everyone older than 50?: FOR. BMJ
330: 1440-1441
[Full Text]
Scherger, J. E
(2005). Primary care needs a new model of office practice. BMJ
330: E358-E359
[Full Text]
Wilson, J. W., Oyen, L. J., Ou, N. N., McMahon, M. M., Thompson, R. L., Manahan, J. M., Graner, K. K., Lovely, J. K., Estes, L. L.
(2005). Hospital rules-based system: The next generation of medical informatics for patient safety. Am J Health Syst Pharm
62: 499-505
[Abstract][Full Text]
Smith, P. C., Araya-Guerra, R., Bublitz, C., Parnes, B., Dickinson, L. M., Van Vorst, R., Westfall, J. M., Pace, W. D.
(2005). Missing Clinical Information During Primary Care Visits. JAMA
293: 565-571
[Abstract][Full Text]
Zellmer, W. A.
(2005). Unresolved issues in pharmacy. Am J Health Syst Pharm
62: 259-265
[Full Text]
Weingart, S. N., Gandhi, T. K., Seger, A. C., Seger, D. L., Borus, J., Burdick, E., Leape, L. L., Bates, D. W.
(2005). Patient-Reported Medication Symptoms in Primary Care. Arch Intern Med
165: 234-240
[Abstract][Full Text]
Tinetti, M. E., Bogardus, S. T. Jr., Agostini, J. V.
(2004). Potential Pitfalls of Disease-Specific Guidelines for Patients with Multiple Conditions. NEJM
351: 2870-2874
[Full Text]
Weingart, S. N., Toth, M., Eneman, J., Aronson, M. D., Sands, D. Z., Ship, A. N., Davis, R. B., Phillips, R. S.
(2004). Lessons from a patient partnership intervention to prevent adverse drug events. Int J Qual Health Care
16: 499-507
[Abstract][Full Text]
Morimoto, T, Gandhi, T K, Seger, A C, Hsieh, T C, Bates, D W
(2004). Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care
13: 306-314
[Abstract][Full Text]
Fernald, D. H., Pace, W. D., Harris, D. M., West, D. R., Main, D. S., Westfall, J. M.
(2004). Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative. Ann Fam Med
2: 327-332
[Abstract][Full Text]
Haga, S. B., Burke, W.
(2004). Using Pharmacogenetics to Improve Drug Safety and Efficacy. JAMA
291: 2869-2871
[Full Text]
Nebeker, J. R., Barach, P., Samore, M. H.
(2004). Clarifying Adverse Drug Events: A Clinician's Guide to Terminology, Documentation, and Reporting. ANN INTERN MED
140: 795-801
[Abstract][Full Text]
Jerome, Y.
(2004). Brace for the Case: Be Prepared for Anaphylaxis. Obstet Gynecol
103: 1043-1044
[Full Text]
Bell, D. S., Cretin, S., Marken, R. S., Landman, A. B.
(2004). A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities. J. Am. Med. Inform. Assoc.
11: 60-70
[Abstract][Full Text]
Avery, A J
(2003). Classifying and identifying errors. Qual Saf Health Care
12: 404-404
[Full Text]
Weingart, S. N., Toth, M., Sands, D. Z., Aronson, M. D., Davis, R. B., Phillips, R. S.
(2003). Physicians' Decisions to Override Computerized Drug Alerts in Primary Care. Arch Intern Med
163: 2625-2631
[Abstract][Full Text]
Hoch, I., Heymann, A. D., Kurman, I., Valinsky, L. J., Chodick, G., Shalev, V.
(2003). Countrywide Computer Alerts to Community Physicians Improve Potassium Testing in Patients Receiving Diuretics. J. Am. Med. Inform. Assoc.
10: 541-546
[Abstract][Full Text]
Hernandez, J., Vargas, M. L., Snow, D., Gandhi, T. K., Weingart, S. N., Bates, D. W., Tierney, W. M.
(2003). Adverse Drug Events in Ambulatory Care. NEJM
349: 303-305
[Full Text]
Kuperman, G. J., Gibson, R. F.
(2003). Computer Physician Order Entry: Benefits, Costs, and Issues. ANN INTERN MED
139: 31-39
[Abstract][Full Text]
Berwick, D. M.
(2003). Errors Today and Errors Tomorrow. NEJM
348: 2570-2572
[Full Text]
Tierney, W. M.
(2003). Adverse Outpatient Drug Events -- A Problem and an Opportunity. NEJM
348: 1587-1589
[Full Text]
Previous
