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Slide Presentation from the AHRQ 2007 Annual Conference

Sources of ADE Information

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Source	Total ADEs	Preventable %
ER notes	187	37%
Hospital D/C's	166	35%
Computer signals	439	34%
Electronic notes	565	20%
Provider reports	168	15%
Incident reports	5	60%

Source: Field, TS et al. JAMA 2004;52:1349-154.

Notes:

Study led by Jerry Gurwitz, David Bates, and Terry Field, funded by National Institute on Aging and AHRQ
~28,000 patients age 65 and older over the course of 1 year.
Systematically looked at each of these sources.
Computer signals were things like:
Digoxin Level >2
ICD9- code for "Poisoning by Cardiovascular Drug"
Potassium <2.9 or INR >5
Rx for Vitamin K
Note that MDs don't record or report their mistakes...

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