Twenty-six percent of patients at a Veterans Affairs medical center in Salt Lake City experienced a clinically significant adverse drug event in the final 20 weeks of 2000, even though the facility used a computerized physician order-entry system that automatically checked for drug allergies and many drug-drug interactions. Because many patients suffered multiple drug events, the actual rate of clinically significant adverse drug events was 52 per 100 admissions, according to a study in today's Archives of Internal Medicine. Nine percent of the events, or 45 out of 483, were serious -- leading to prolonged hospitalization, permanent harm, death or near death. Twenty-seven percent resulted from medication errors, such as incorrect medication or dose or inadequate monitoring of patients.
Lead author Jonathan Nebeker, an attending physician at the VA's Salt Lake City Health Care System, said the study underscored the need to develop computerized decision-support systems aimed at the most troublesome types of adverse events. "Many studies have shown that human beings can only simultaneously consider four independent factors in decisions," Nebeker said in an e-mail interview. "It is common to have to consider 10 to 20 simultaneous factors in patient medication decisions." Read the abstract. -- by Andis Robeznieks