Elsevier

Kidney International

Volume 76, Issue 11, 1 December 2009, Pages 1192-1198
Kidney International

Original Article
Occurrence of adverse, often preventable, events in community hospitals involving nephrotoxic drugs or those excreted by the kidney

https://doi.org/10.1038/ki.2009.353Get rights and content
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Medication errors in patients with reduced creatinine clearance are harmful and costly; however, most studies have been conducted in large academic hospitals. As there are few studies regarding this issue in smaller community hospitals, we conducted a multicenter, retrospective cohort study in six community hospitals (100 to 300 beds) to assess the incidence and severity of adverse drug events (ADEs) in patients with reduced creatinine clearance. A chart review was performed on adult patients hospitalized during a 20-month study period with serum creatinine over 1.5 mg/dl who were exposed to drugs that are nephrotoxic or cleared by the kidney. Among 109,641 patients, 17,614 had reduced creatinine clearance, and in a random sample of 900 of these patients, there were 498 potential ADEs and 90 ADEs. Among these ADEs, 91% were preventable, 51% were serious, 44% were significant, and 4.5% were life threatening. Of the potential ADEs, 54% were serious, 44% were significant, 1.6% were life threatening, and 96.6% were not intercepted. All 82 preventable events could have been intercepted by renal dose checking. Our study shows that ADEs were common in patients with impaired kidney function in community hospitals, and many appear potentially preventable with renal dose checking.

Keywords

computerized physician order entry
medication error
multicenter

Cited by (0)

This study was funded by the Massachusetts Technology Collaborative, which is not responsible for the contents of the paper. Dr Bates is a co-inventor on patent no. 6029138 held by Brigham and Women's Hospital on the use of decision support software for medical management, licensed to the Medicalis Corporation. He holds a minority equity position in the privately held company Medicalis, which develops web-based decision support for radiology test ordering, and serves as a consultant to Medicalis. He is a consultant for Cardinal Health, which makes intravenous drug delivery systems. Dr Hug has received financial funding from the Freie Akademische Gesellschaft, the Walter and Margarethe Lichtenstein Fund, and the University Hospital in Basel, Switzerland.