Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2009 Feb;18(1):32-6.
doi: 10.1136/qshc.2007.025957.

Prescribing discrepancies likely to cause adverse drug events after patient transfer

K S Boockvar  1 , S Liu, N Goldstein, J Nebeker, A Siu, T Fried
Affiliations

Prescribing discrepancies likely to cause adverse drug events after patient transfer

K S Boockvar et al. Qual Saf Health Care. 2009 Feb.

Abstract

Background: Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing.

Methods: We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs.

Results: 208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1-2 and >/=3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively.

Conclusions: Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

PubMed Disclaimer

References

    1. Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545–550. - PubMed
    1. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842–1847. - PubMed
    1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–651. - PMC - PubMed
    1. The Joint Commission. Hospitals’ National Patient Safety Goals. [Accessed November 13, 2007]. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/....
    1. Massachusetts Coalition for the Prevention of Medical Errors. Reconciling Medications. [Accessed November 13, 2007]. Available at: http://www.macoalition.org/Initiatives/RecMeds/ProjectBackground.pdf.

Publication types

Substances