Emergency re-admissions to hospital due to adverse drug reactions within 1 year of the index admission.

AIM: The proportion of re-admissions to hospital caused by ADRs is poorly documented in the UK. The aim of this study was to evaluate the impact of ADRs on re-admission to hospital after a period as an inpatient. METHODS: One thousand patients consecutively admitted to 12 wards were included. All subsequent admissions for this cohort within 1 year of discharge from the index admission were retrospectively reviewed. RESULTS: Of the 1000 patients included, 403 (40.3%, 95% CI 39.1, 45.4%) were re-admitted within 1 year. Complete data were available for 290 (70.2%) re-admitted patients, with an ADR contributing to admission in 60 (20.8%, 95% CI 16.4, 25.6%) patients. Presence of an ADR in the index admission did not predict for an ADR-related re-admission (10.5% vs. 7.2%, P=0.25), or re-admission overall (47.2% vs. 41.2%, P=0.15). The implicated drug was commenced in the index admission in 33/148 (22.3%) instances, with 37/148 (25%) commenced elsewhere since the index admission. Increasing age and an index admission in a medical ward were associated with a higher incidence of re-admission ADR. The most frequent causative drugs were anti-platelets and loop diuretics, with bleeding and renal impairment the most frequent ADRs. Over half (52/91, 57.1%) of the ADRs were judged to be definitely or possibly avoidable. CONCLUSIONS: One fifth of patients re-admitted to hospital within 1 year of discharge from their index admission are re-admitted due to an ADR. Our data highlight drug and patient groups where interventions are needed to reduce the incidence of ADRs leading to re-admission.

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Adverse drug reactions (ADRs) are a reporting category in the National Patient Safety Agency (NPSA) incident reporting system, though the Medicines and Healthcare Products Regulatory Agency (MHRA) pharmacovigilance system is the more established method for collecting ADR data. WHAT THIS STUDY ADDS: The majority of ADRs were shown to be of moderate risk to the patient, though some have a severe or catastrophic impact. Classification and reporting of ADRs according to NPSA guidance is possible but offers limited additional value to efforts to improve patient safety over and above the Yellow Card Scheme. AIM: In the UK, the National Patient Safety Agency (NPSA) includes adverse drug reactions as a reporting category, while the MHRA Yellow Card Scheme also collects data regarding adverse drug reactions (ADRs). In this study, we aimed to assess ADRs using NPSA criteria and discuss the resulting implications. METHODS: ADRs identified in a 6-month prospective study of 3695 inpatient episodes were assessed according to their impact on the patient and on the organization, using tools developed by the NPSA. RESULTS: Seven hundred and thirty-three (100%) ADRs were assessed. In terms of impact on the patient, 537 (73.3%) were categorized as 'low' (minor treatment), 181 (24.7%) as 'moderate' (moderate increase in treatment, no permanent harm), 14 (1.91%) as 'severe' (permanent harm) and 1 (0.14%) was categorized as 'catastrophic' (direct cause of death). In terms of impact on the organization, none was categorized as 'no harm/no risk', 508 (69.3%) as 'insignificant', 188 (25.6%) as 'minor', 25 (3.4%) as 'moderate', 12 (1.6%) as 'major' and none was classed as 'catastrophic'. Less than 2% of ADRs would be eligible for detailed analysis according to the NPSA guidance. The ADRs that cause incidents of greater significance relate to bleeding, renal impairment and Clostridium difficile infection. CONCLUSIONS: Classification of ADRs according to NPSA guidance offers limited additional value over and above that offered by the Yellow Card System. A consistent message needs to be sent to prospective reporters of ADRs; the availability of more than one system is likely to confuse reporters and does not aid patient safety.

Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes.

Adverse drug reactions (ADRs) are a major cause of hospital admissions, but recent data on the incidence and clinical characteristics of ADRs which occur following hospital admission, are lacking. Patients admitted to twelve wards over a six-month period in 2005 were assessed for ADRs throughout their admission. Suspected ADRs were recorded and analysed for causality, severity and avoidability and whether they increased the length of stay. Multivariable analysis was undertaken to identify the risk factors for ADRs. The 5% significance level was used when assessing factors for inclusion in multivariable models. Out of the 3695 patient episodes assessed for ADRs, 545 (14.7%, 95% CI 13.6-15.9%) experienced one or more ADRs. Half of ADRs were definitely or possibly avoidable. The patients experiencing ADRs were more likely to be older, female, taking a larger number of medicines, and had a longer length of stay than those without ADRs. However, the only significant predictor of ADRs, from the multivariable analysis of a representative sample of patients, was the number of medicines taken by the patient with each additional medication multiplying the hazard of an ADR episode by 1.14 (95% CI 1.09, 1.20). ADRs directly increased length of stay in 147 (26.8%) patients. The drugs most frequently associated with ADRs were diuretics, opioid analgesics, and anticoagulants. In conclusion, approximately one in seven hospital in-patients experience an ADR, which is a significant cause of morbidity, increasing the length of stay of patients by an average of 0.25 days/patient admission episode. The overall burden of ADRs on hospitals is high, and effective intervention strategies are urgently needed to reduce this burden.

Attitudes and opinions of nursing and medical staff regarding the supply and storage of medicinal products before and after the installation of a drawer-based automated stock-control system.

OBJECTIVES: This study assessed the attitudes of Emergency Department (ED) staff regarding the introduction of an automated stock-control system. The objectives were to determine attitudes to stock control and replenishment, speed of access to the system, ease of use and the potential for future uses of the system. The study was carried out in the Countess of Chester Hospital NHS Foundation Trust (COCH) ED, which is attended by over 65,000 patients each year. METHODS: All 68 ED staff were sent pre-piloted, semi-structured questionnaires and reminders, before and after automation of medicines stock control. KEY FINDINGS: Pre-implementation, 35 staff (66.1% of respondents) reported that problems occurred with access to medicine storage keys 'very frequently' or 'frequently'. Twenty-eight (52.8%) respondents 'agreed' or 'strongly agreed' that medicines were quickly accessed, which rose to 41 (77%) post-automation (P < 0.001). Improvement was reported in stock replenishment and storage of stock injections and oral medicines, but there were mixed opinions regarding storage of bulk fluids and refrigerated items. Twenty-seven (51.9%) staff reported access to the system within 1 min and 17 (32.7%) staff reported access within 1-2 min. The majority of staff found the system 'easy' or 'very easy' to use and there was a non-significant relationship between previous use of information technology and acceptance of the system. CONCLUSIONS: From a staff satisfaction perspective, automation improved medicines storage, security and stock control, and addressed the problem of searching for keys to storage areas. Concerns over familiarity with computers, queuing, speed of access and an improved audit trail do not appear to have been issues, when compared with the previous manual storage of medicines.

Adverse drug reactions in hospitals: a narrative review.

The serious nature of adverse drug reactions (ADRs) has been highlighted in a number of instances over the last forty years, the most recent of these being the occurrence of serious thrombotic events with the use of COX-2 inhibitors. ADRs are estimated to be between the 4(th) and 6(th) leading cause of death in the USA, with fatal ADRs occurring in 0.32% of patients. A recent UK study showed that 6.5% of hospital admissions were related to ADRs. ADRs can therefore be regarded as a significant public health and economic problem. There is an urgent need to develop better preventive strategies to reduce the burden of ADRs. Because ADRs can affect any bodily system, can have many different clinical presentations, and are of widely variable severity, prevention will not be easy and will have to be multifactorial in its approach. This paper reviews the epidemiology of ADRs in hospitals and evaluates the research that has been undertaken to date to prevent ADRs.

Elimination of ephedrines in urine following multiple dosing: the consequences for athletes, in relation to doping control.

AIMS: To study the elimination of ephedrines with reference to the International Olympic Committee (IOC) doping control cut-off levels, following multiple dosing of over-the-counter decongestant preparations. METHODS: A double-blind study was performed in which 16 healthy male volunteers were administered either pseudoephedrine or phenylpropanolamine in maximal recommended therapeutic doses over a 36-h period. Urine was collected every two hours between 08:00 and 24:00 h and at 04:00 h throughout the testing period of three days. Urine drug levels were quantified using high performance liquid chromatography. Side-effects were assessed, including heart rate and blood pressure, every four hours between 08:00 and 20:00 h. RESULTS: Mean (95% CI) total phenylpropanolamine and pseudoephedrine eliminated unchanged was 75 (88, 61) and 81 (92, 71)%, respectively. Maximum urine concentrations of phenylpropanolamine and pseudoephedrine were 112.1 (164.2, 59.9) and 148.5 (215.0, 82.1) mg.l(-1), respectively. A peak in drug urine concentration occurred four hours following the final dose. There were no adverse cardiovascular effects and only mild CNS stimulation was evident. CONCLUSIONS: Following therapeutic, multiple dosing, drug levels remain above the IOC cut-off levels for a minimum of 6 h and 16 h following final doses of phenylpropanolamine and pseudoephedrine, respectively. Athletes require informed advice on this from their healthcare professionals.