Avoidable Post Hospital Discharge Errors Are Common

Adverse events after discharge from the hospital are common. Many of these adverse events are avoidable or ameliorable.

400 consecutive patients discharged home from the general medical service of a tertiary care academic hospital were followed in one study. After discharge, 76 patients (19%) had adverse events, defined as injuries occurring as a result of poor medical management. Of these, 23 patients had preventable adverse events, defined as adverse events judged to have been caused by an error, and 24 patients had ameliorable adverse events, defined as adverse events in which the severity could have been decreased.

Adverse drug events accounted for 66% of adverse events, and procedure-related injuries for 17%. Of the 25 adverse events that caused a transient or permanent disability, 12 events were preventable and six events were ameliorable.
Adverse drug events [ADEs] are almost as common among outpatients and they have important litigation consequences.

A summary analysis of more than 1500 published case reports of ADEs yielded information on possible risk factors for drug-related deaths, disabilities, and life threats and on which events may have been preventable.

The study showed that the drug categories most commonly involved in ADEs were central-nervous-system agents, antimicrobials, antineoplastics, and cardiovascular agents.

CAUSES OF ADES

Faulty prescribing was the most common reason for medication error, and
Wrong dosage was the most common type of error.
Overall, 52% of the cases were judged to have been preventable;
Of these, 50% could have been prevented by a pharmacist.

Litigation was reported for 13% of the cases; Settlements and judgments averaged $3.1 million.


Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. Am J Health Syst Pharm. 2001;58:1399-1405.

Ann Intern Med. 2003;138:161-167
Comment: “In theory, there is no difference between theory and practice. In practice there is.”- Yogi Berra

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