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A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents

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      Abstract

      BACKGROUNDEach July thousands begin medical residencies and acquire increased responsibility for patient care. Many have suggested that these new medical residents may produce errors and worsen patient outcomes—the so-called “July Effect;” however, we have found no U.S. evidence documenting this effect.OBJECTIVEDetermine whether fatal medication errors spike in July.DESIGNWe examined all U.S. death certificates, 1979–2006 (n = 62,338,584), focusing on medication errors (n = 244,388). We compared the observed number of deaths in July with the number expected, determined by least-squares regression techniques. We compared the July Effect inside versus outside medical institutions. We also compared the July Effect in counties with versus without teaching hospitals.OUTCOME MEASUREJR = Observed number of July deaths / Expected number of July deaths.RESULTSInside medical institutions, in counties containing teaching hospitals, fatal medication errors spiked by 10% in July and in no other month [JR = 1.10 (1.06–1.14)]. In contrast, there was no July spike in counties without teaching hospitals. The greater the concentration of teaching hospitals in a region, the greater the July spike (r = .80; P = .005). These findings held only for medication errors, not for other causes of death.CONCLUSIONSWe found a significant July spike in fatal medication errors inside medical institutions. After assessing competing explanations, we concluded that the July mortality spike results at least partly from changes associated with the arrival of new medical residents.

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      Most cited references 38

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      Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

      Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting. To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting. Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors. Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable. There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events. Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.
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        Incidence of Adverse Drug Reactions in Hospitalized Patients

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          Medication errors observed in 36 health care facilities.

          Medication errors are a national concern. To identify the prevalence of medication errors (doses administered differently than ordered). A prospective cohort study. Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. Medication errors reaching patients. In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04) Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.
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            Author and article information

            Affiliations
            [1 ]Department of Sociology, University of California at San Diego, 0533, 9500 Gilman Drive, La Jolla, CA 92093-0533 USA
            [2 ]School of Public Health, University of California at Los Angeles, Los Angeles, CA USA
            Contributors
            +1-858-5340482 , +1-858-5344753 , dphillips@ucsd.edu
            Journal
            J Gen Intern Med
            Journal of General Internal Medicine
            Springer-Verlag (New York )
            0884-8734
            1525-1497
            29 May 2010
            29 May 2010
            August 2010
            : 25
            : 8
            : 774-779
            2896592
            20512532
            1356
            10.1007/s11606-010-1356-3
            © The Author(s) 2010
            Categories
            Original Research
            Custom metadata
            © Society of General Internal Medicine 2010

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