LO91: Repeat exposures to culprit drugs contribute to adverse drug events in emergency department patients

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million annual emergency department (ED) visits in Canada. Australian data indicate that 27% of ADEs requiring admission are events caused by re-exposure to drugs that previously caused harm. Our objective was to estimate the frequency of repeat ADEs. Methods: We reviewed the charts of ADE patients who had been enrolled in 1 of 3 prospective studies conducted in 2 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal association between the drug regimens and patient presentations. After completion of the parent studies, a research pharmacist and a physician independently reviewed the charts of ADE patients, abstracted data using electronic forms, and searched that hospital’s records for previously recorded ADEs. The main outcome was a repeat ADE, defined as a same or same-class drug re-exposure, or repeat inappropriate drug withdrawal, causing a same or similar presentation as a prior ADE. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 614 ED patients diagnosed with 655 ADEs. Of these, 20% (133/665, 95%CI 17.0-23.0%) were repeat events. Most repeat ADEs were moderate (61%) or severe (32%) in nature, and 33% (95%CI 25.1-41.1%) required hospital admission. The most commonly implicated drugs were warfarin (10%), hydrochlorothiazide (4%) and insulin (4%), and the most commonly implicated drug classes were antithrombotics (17%), psychotropics (12%) and analgesics (9%). Repeat ADEs commonly required clinical monitoring (59%), additional medications to treat the ADE (50%) and follow-up lab testing (35%). Overall, 61% (95%CI 51.3-70.7%) of culprit drug re-exposures were deemed potentially or definitely inappropriate. Conclusion: Inappropriate re-exposures to previously harmful medications cause a substantial number of recurrent ADEs, and may represent an ideal target for prevention. We were unable to search for repeat ADEs in the records of other hospitals that our patients may have visited, and could not detect ADEs that were not documented in the medical record. As a result, we likely underestimated the frequency of repeat ADEs.

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P061: Preventable adverse drug events in Canadian emergency departments

CJEM ◽

10.1017/cem.2017.263 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S98-S99

Author(s):

C.M. Hohl ◽

S. Woo ◽

A. Cragg ◽

C.R. Ackerley ◽

M.E. Wickham ◽

...

Keyword(s):

Mental Health ◽

Adverse Drug Events ◽

Tertiary Care ◽

Rater Agreement ◽

Adherence Behavior ◽

Drug Regimens ◽

Ed Visits ◽

Mental Health Diagnoses ◽

Systematic Selection ◽

Preventable Ades

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.

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LO92: Factors contributing to the development of adverse drug events treated in emergency departments

CJEM ◽

10.1017/cem.2017.154 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S59-S60 ◽

Cited By ~ 3

Author(s):

S. Woo ◽

A. Cragg ◽

M.E. Wickham ◽

C.R. Ackerley ◽

D. Villanyi ◽

...

Keyword(s):

Adverse Drug Events ◽

Treatment Guidelines ◽

Tertiary Care ◽

Patient Counseling ◽

Contributing Factors ◽

Recommended Treatment ◽

Drug Regimens ◽

System Factors ◽

Systematic Selection

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, commonly cause or contribute to emergency department (ED) presentations. Understanding provider, patient and system factors that contribute to their development may assist in developing effective preventative strategies. Our objective was to identify factors that contributed to the development of ADEs that caused ED presentations. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal associations between the drug regimens and patient presentations. Subsequently, a research pharmacist and physician independently reviewed the charts of ADE patients from these cohorts, abstracting data using electronic forms. Reviewers recorded patient, provider and system factors that contributed to the development of ADEs. The main outcome was the presence of at least one contributing factor in the development of an ADE. We used descriptive statistics with appropriate measures of variance. The sample size was determined by enrolment into the primary studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We identified ≥1 contributing factors in 62% (95%CI 58-65%) of ADEs. Multiple contributing factors were present in 17% of ADEs (95%CI 13-20%). The most common contributing factors were inadequate patient counseling or instructions about medication use (15%), insufficient laboratory monitoring or follow-up of monitoring tests (12%), lack of staff education (7%), lack of provider adherence with recommended treatment guidelines (7%), and delayed or inadequate clinical reassessment after a medication change (6%). Provider errors in drug administration contributed to 0.3% of ADEs (95%CI 0.0-0.7). Conclusion: Contributing factors were identified for most ADEs. They were often related to inadequate counseling and follow-up, and were rarely the result of errors. Further research is required to understand how communication of medication instructions can be improved. Investments in technologies to reduce provider errors may not significantly reduce the numbers of ADE patients presenting to EDs.

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How do we manage emergency department patients diagnosed with transient ischemic attack?

CJEM ◽

10.2310/8000.2011.110533 ◽

2012 ◽

Vol 14 (01) ◽

pp. 20-24 ◽

Cited By ~ 7

Author(s):

Jeffrey J. Perry ◽

Jonathan Kerr ◽

Cheryl Symington ◽

Jane Sutherland

Keyword(s):

Emergency Department ◽

Transient Ischemic Attack ◽

Data Extraction ◽

Tertiary Care ◽

Clinical Findings ◽

Stroke Rate ◽

Historical Cohort ◽

History Of ◽

Emergency Department Patients ◽

Ischemic Attack

ABSTRACTIntroduction:Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA.Methods:We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded.Results:A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%.Conclusions:This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.

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10 Clinical Decision Rules to Improve the Detection of Adverse Drug Events in Emergency Department Patients

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2011.06.035 ◽

2011 ◽

Vol 58 (4) ◽

pp. S180-S181

Author(s):

C.M. Hohl ◽

E. Yu ◽

G.S. Hunte ◽

J.R. Brubacher ◽

F. Hosseini ◽

...

Keyword(s):

Emergency Department ◽

Adverse Drug Events ◽

Decision Rules ◽

Clinical Decision ◽

Clinical Decision Rules ◽

Emergency Department Patients

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Point of Care Ultrasound First: An Opportunity to Improve Efficiency for Uncomplicated Pregnancy in the Emergency Department

POCUS Journal ◽

10.24908/pocus.v6i1.14762 ◽

2021 ◽

Vol 6 (1) ◽

pp. 42-44

Author(s):

Sara Urquhart ◽

Kendall Stevens ◽

Mariah Barnes ◽

Matthew Flannigan

Keyword(s):

Emergency Department ◽

Random Sample ◽

Medical Center ◽

Point Of Care ◽

Tertiary Care ◽

Radiology Department ◽

Point Of Care Ultrasound ◽

Tertiary Care Medical Center ◽

Time To Diagnosis ◽

Emergency Department Patients

Introduction: Research suggests emergency providers using point-of-care ultrasound (POCUS) to confirm an uncomplicated intrauterine pregnancy (IUP) can decrease emergency department (ED) length of stay (LOS) compared to a radiology department ultrasound (RADUS). The objective of this study was to compare the time to diagnosis and LOS between POCUS and RADUS patients. Methods: This was a retrospective study at one urban medical center. A standardized tool was used to abstract data from a random sample of pregnant patients diagnosed with uncomplicated IUP between January 2016 and December 2017 at a single tertiary care medical center. Microsoft Excel 2010 software was used to measure time intervals, prepare descriptive statistics, and perform Mann-Whitney U tests to compare differences. Results: A random sample of 836 (36%) of the 2,346 emergency department patients diagnosed with an IUP between 8-20 weeks’ gestation during the study period was evaluated for inclusion. Three hundred sixty-six met inclusion criteria and were included in the final analysis. Patients were divided into 2 groups based on which type of ultrasound scan they received first: POCUS (n=165) and RADUS (n=201). Patients who received POCUS were found to have an IUP identified in an average of 48 minutes (95% CI, 43 to 53), while the RADUS group’s mean time to diagnosis was 120 minutes (95% CI 113 to 127) with a difference of 72 minutes (95% CI, 63 to 80; p<0.001). The mean LOS for patients who received POCUS was 132 minutes (95% CI, 122 to 142), while that of the RADUS group was 177 minutes (95% CI 170 to 184) with a difference of 45 minutes (95% CI 32 to 56; p<0.001). The study is limited by its single-center, retrospective design and by lack of blinding of data abstractors. Conclusion: Pregnant emergency department patients diagnosed with an uncomplicated IUP between 8-weeks and 20-weeks’ gestation had statistically significant reduction in time to diagnosis and disposition from the ED if assessed with POCUS as compared to RADUS.

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Inappropriateness of Repeated Laboratory and Radiological Tests for Transferred Emergency Department Patients

Journal of Clinical Medicine ◽

10.3390/jcm8091342 ◽

2019 ◽

Vol 8 (9) ◽

pp. 1342 ◽

Cited By ~ 2

Author(s):

Jérôme Bertrand ◽

Christophe Fehlmann ◽

Olivier Grosgurin ◽

François Sarasin ◽

Omar Kherad

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Regression Analysis ◽

Laboratory Tests ◽

Chart Review ◽

Primary Outcome ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Emergency Department Patients ◽

Radiological Procedures

Background: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. Methods: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. Results: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. Conclusion: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.

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Identification of emergency department patients for referral to rapid-access addiction services

CJEM ◽

10.1017/cem.2019.453 ◽

2020 ◽

Vol 22 (2) ◽

pp. 170-177 ◽

Cited By ~ 1

Author(s):

Jessica Hann ◽

Howie Wu ◽

Aliyah Gauri ◽

Kathryn Dong ◽

Ni Lam ◽

...

Keyword(s):

Health Care ◽

Emergency Department ◽

High Risk ◽

Tertiary Care ◽

Health Care Team ◽

Care Team ◽

Rapid Access ◽

Addiction Services ◽

Ed Visits ◽

Emergency Department Patients

ABSTRACTObjectivesSubstance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED.MethodsThis prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available.ResultsWe received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated “Yes” for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period.ConclusionsAt least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.

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