Million for Patient Safety
Research and Practice
Penn 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
medication errors are among the most common--and potentially preventable--types
of medical errors," said Dr. Brian L. Strom, director of the new
center and chair of the 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
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.
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
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.
there is no single cause for this problem--and no single solution,
either," said Dr. 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 errors."
investigators come from 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 HUP's Drug Use and Effects Program to reduce medication
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.
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 in hospitalization. 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.
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 error rates.
our work cut out for us, but this is not an impossible mission,"
said Dr. 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."
Almanac, Vol. 48, No. 9, October 23, 2001
October 23, 2001
Volume 48 Number 9