Prevention of Medication Errors in Hospitalized Patients: The Japan Adverse Drug Events Study
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The nature of medication errors (MEs) and the frequency of identified or intercepted MEs are not being scrutinized in daily practice in Japan.
The aim of this study was to clarify the epidemiology of MEs and the risk factors for non-intercepted and unidentified MEs.
The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive patients (N = 3459) aged ≥15 years who were admitted to the study wards. MEs were identified by on-site reviews of all medical charts, self-reports, and prescription queries by pharmacists. Two independent physicians reviewed and classified all MEs and adverse drug events and determined the stages at which the MEs occurred and whether there was interception or identification of the MEs.
A total of 514 MEs were observed among 433 patients. Sixty-four percent of MEs occurred at the ordering stage. Among these, 60 % were due to duplicate drug orders. Overall, 63 % and 45 % of MEs were not intercepted or identified during hospitalization, respectively. The independent risk factors for non-intercepted MEs were hospitalization in the surgical ward (odds ratio [OR] 2.94) and the intensive care unit (OR 3.57). MEs by resident physicians were more likely to be intercepted (OR 0.52 for non-intercepted MEs).
MEs frequently occurred and most at the ordering stage. Almost half of MEs were not intercepted or identified. Many MEs at the later stages were less likely to be intercepted and resulted in actual patient harm. Systems to improve the identification and interception of MEs should be implemented.
KeywordsResident Physician Multivariable Logistic Regression Model Computerize Physician Order Entry Wrong Dose Potential ADEs
The JADE study for adult inpatients was conducted with the following investigators: Kunihiko Matsui, MD, MPH, Nobuo Kuramoto, MD, Jinichi Toshiro, MD, Junji Murakami, MD, Tsuguya Fukui, MD, MPH, Mayuko Saito, MD, MPH, and Atsushi Hiraide, MD. We are also indebted to Ms Makiko Ohtorii, Ms Ai Mizutani, Ms Mika Sakai, Ms Izumi Miki, Ms Kimiko Sakamoto, Ms Eri Miyake, Ms Takako Yamaguchi, Ms Yoko Oe, Ms Kyoko Sakaguchi, Ms Kumiko Matsunaga, Ms Yoko Ishida, Ms Kiyoko Hongo, Ms Masae Otani, Ms Yasuko Ito, Ms Ayumi Samejima, and Ms Shinobu Tanaka for their data collection and management.
Compliance with Ethical Standards
This work was supported by JSPS KAKENHI Grant Numbers JP17689022, JP21659130, JP22390103, JP23659256, JP26293159, and Grants from the Ministry of Health, Labour and Welfare of Japan, Grants from the Pfizer Health Research Foundation and the Uehara Memorial Foundation.
Conflict of interest
Chihiro Noguchi, Mio Sakuma, Yoshinori Ohta and Takeshi Morimoto have no conflicts of interest that are directly relevant to the content of this study. David Bates has received equity from Intensix, which makes software to support clinical decision-making in intensive care; being named as coinventor 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, and holding a minority equity position in Medicalis, which develops web-based decision support for radiology test ordering; consulting for EarlySense, which makes patient safety monitoring systems; receiving equity and cash compensation from QPID Inc., a company focused on intelligence systems for electronic health records; receiving cash compensation from CDI (Negev) Ltd, which is a not-for-profit incubator for health IT startups; receiving equity from Enelgy, which makes software to support evidence-based clinical decisions, from Ethosmart, which makes software to help patients with chronic diseases, and from MDClone, which takes clinical data and produces deidentified versions of it.
This study was approved by all institutional review boards at all participating hospitals and was conducted in accordance with the provisions of the Declaration of Helsinki and the ethical guidelines for clinical studies in Japan.