Providing hospitalized patients with a list of their medications, a glossary of common drug prescribing terms (for example, BID for twice a day), and a one-page medication safety guide may be an effective way to reduce injuries due to drug errors (adverse drug events, ADEs), according to the results of a pilot study. Although the researchers found no significant differences in ADEs, close calls, or care experiences between intervention and control patients (controls received the one-page consumer guide only), more than one-fourth of nurses reported that medication errors were prevented because a patient or family member in the intervention group identified drug-related problems. The study was supported in part by the Agency for Healthcare Research and Quality (K08 HS11644).
Saul N. Weingart, M.D., Ph.D., of Beth Israel Deaconess Medical Center and Harvard Medical School, and his colleagues randomly assigned 209 adult patients on a hospital general medicine unit to intervention and control groups. The researchers reviewed medical charts and incident reports from nurses, pharmacists, and physicians to identify ADEs and close-call drug errors. They also surveyed patients and clinicians.
During the total 1,053 patient days, 11 patients experienced 12 ADEs, and 16 patients experienced 18 close calls. The ADE rate in the intervention group (8.4 percent) exceeded the rate in the control group (2.9 percent), while the close-call rate was lower in the intervention group (7.5 percent) compared with the control group (9.8 percent). Neither comparison resulted in a statistically significant difference. Twenty-nine percent of nurse respondents indicated that at least one medication error was prevented when an intervention patient or family member identified a problem.
The lack of intervention effect may have been due, in part, to the fact that half of ADEs and three-quarters of close calls occurred after admission but before enrollment in the study the next morning, notes Dr. Weingart. Also, the study size may have been too small to detect a significant difference between the groups. Thus, the researchers call for further study to document the efficacy of this patient-partnering approach to drug safety.
See "Lessons from a patient partnership intervention to prevent adverse drug events," by Dr. Weingart, Maria Toth, Jonathan Eneman, and others, in the International Journal for Quality in Health Care 16(6), pp. 499-507, 2004.
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