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Jonathan R. Nebeker, MS, MD; Jennifer M. Hoffman, PharmD; Charlene R. Weir, RN, PhD; Charles L. Bennett, MD, PhD, MPP; John F. Hurdle, MD, PhD

Arch Intern Med. 2005;165:1111-1116.

Background  Numerous studies have shown that specific computerized interventions may reduce medication errors, but few have examined adverse drug events (ADEs) across all stages of the computerized medication process. We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple computerized medication ordering and administration systems, including computerized physician order entry (CPOE).

Methods  Using explicit standardized criteria, pharmacists classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of all admissions during a 20-week period at a Veterans Administration hospital. We analyzed ADEs that necessitated a changed treatment plan.

Results  Among 937 hospital admissions, 483 clinically significant inpatient ADEs were identified, accounting for 52 ADEs per 100 admissions and an incidence density of 70 ADEs per 1000 patient-days. One quarter of the hospitalizations had at least 1 ADE. Of all ADEs, 9% resulted in serious harm, 22% in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone; 27% should have resulted in additional interventions or monitoring. Medication errors contributed to 27% of these ADEs. Errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing, and 0% transcription. The medical record reflected recognition of 76% of the ADEs.

Conclusions  High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing, and monitoring.

Author Affiliations: Veterans Administration Salt Lake City Health Care System, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah (Drs Nebeker, Hoffman, Weir, and Hurdle); Department of Medicine (Drs Nebeker and Hurdle), Department of Medical Informatics (Drs Weir and Hurdle), and Department of Pharmacy Practice (Dr Hoffman), University of Utah, Salt Lake City; and Veterans Administration Midwest Center for Health Services and Policy Research, Lakeside Division, Division of Hematology/Oncology, Department of Medicine, Northwestern University, Chicago, Ill (Dr Bennett).

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