| October 17, 2001
Reducing the Risk of Medication Errors
Announcing the Penn Center for Patient Safety Research
PA) - The University of Pennsylvania Medical Center
has assembled a multidisciplinary team of physicians
and researchers to form the Center of Excellence for
Patient Safety Research and Practice. A $7 million grant
from the Agency for Healthcare Research and Quality
(AHRQ) will fund the center through its first five years
of operation. The center's mission will be to examine
medication errors and address practical ways to prevent
their often-fatal effects.
"Sadly, medication errors are among the most common
- and potentially preventable - types of medical errors,"
said Brian L. Strom, MD, MPH, director of the new
center and chair of the Penn Department of Biostatistics
and Epidemiology. "They account for more deaths
each year than motor vehicle accidents, breast cancer,
or HIV infection - at an annual cost of $17 to $29 billion."
Of course, much is already known about medication errors.
The elderly are most often at risk for such complications.
Anticonvulsants are among the high-risk drugs. So are
digoxin (also known as Lanoxin), used to treat congestive
heart failure, and anticoagulants, such as warfarin
(also known as Coumadin). The most common effects of
medication errors are internal bleeding and kidney failure.
There are many causes of medication errors, and they
can occur anywhere in the medication use process, including
diagnosis, prescribing, dispensing, administering, ingesting,
and monitoring. Among healthcare professionals, factors
such as work stress, distractions, interruptions, inadequate
training, fragmented information, or information overload
may increase the risk of committing errors in the handling
and monitoring of drugs.
Moreover, medication errors are also a societal issue.
Patients often cannot - or do not - adhere to prescribed
drug regimens, an error that accounts for almost a quarter
of all hospital admissions attributed to drugs. Poor
adherence can take the form of overuse, under-use, or
erratic use of the drug. Among patients, factors such
as advanced age, frailty, cultural or literacy barriers,
mental illness or incapacity, or lack of adequate social
support have all been found to contribute to the inability
to adhere to prescribed drug regimens.
"Clearly, there is no single cause for this problem
- and no single solution, either," said Strom.
"But it is a problem that can be solved, and this
center brings together researchers that will address
both the clinical and societal issues behind medication
Indeed, the center's investigators hail a host of different
backgrounds, including pharmaceutical epidemiology,
health services research, biostatistics, occupational
medicine, sociology, psychology, and economics. They
will be drawing on Penn's 20 years of experience in
studying medication safety problems to conduct multidisciplinary
research and education programs designed to identify
and implement systematic approaches to reducing errors.
The AHRQ grant is also recognition of the success and
prominence of the Hospital of the University of Pennsylvania's
Drug Use and Effects Program in to reduce medication
The center has already designed four inaugural projects
that attack the problem of medication errors in real-world
clinical settings. The projects are based at Penn and
linked to the government of the Commonwealth of Pennsylvania
as well as a national network of medication education
and research centers.
The first project investigates factors that may predispose
elderly patients to hospitalizations due to errors in
medication use. For this project, collaboration with
a state-run, population-based pharmaceutical benefit
program will greatly enhance the ability to widely examine
dose-related medication errors among elderly individuals
taking specific high-risk drugs. This project should
help create a prediction rule to identify and decrease
medication errors in high-risk patients that result
The second project tackles error from the direction
of adherence, researching indicators that predict poor
adherence to warfarin therapy in an anticoagulation
clinic. Outcomes from this project should help develop
a predictive index that will allow healthcare workers
to identify which patients are at risk for medication
errors before they begin therapy.
The third project studies medication errors as the cause
of preventable kidney failure among hospital inpatients.
The researchers will examine the preexisting pharmaceutical
monitoring system and determine how the system can be
improved to decrease medication errors.
The fourth project examines the sociological and organizational
causes of medication errors at the clinical level. The
center will study the extent to which workplace conditions
lead to medication errors among physicians, with emphasis
on stress-inducing conditions, such as workload, schedules,
work organization, shifts, and patient/staff ratios.
Results could help design systems that decrease stress
on health professionals and in turn, decrease prescription
"We have our work cut out for us, but this is not
an impossible mission," said Strom. "The ultimate
goal of this center is to determine practical methods
to decrease these errors in order to improve patient
health and lower medical costs."
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