PSA Advisories

Analysis of Reported Drug Interactions: A Recipe for Harm to Patients

Patients admitted to a hospital often receive many medications. Concomitant use of multiple medications can lead to drug interactions that occur prior to administration (i.e., drug incompatibility) or after ingestion or injection (i.e., drug-drug interaction). When an interaction occurs, the effects and characteristics of the drugs may be altered, leading to increased or decreased drug activity or new and unanticipated adverse effects. Analysts searched the Pennsylvania Patient Safety Reporting System database for reports submitted as “Medication error/Monitoring error/Drug-drug interaction” that occurred from April 2009 through March 2016. A total of 815 event reports were included in the final analysis. The most commonly reported type of drug interaction involved drug incompatibilities (41.8%, n = 341) and drug-drug interactions (27.9%, n = 227). Healthcare facilities can help reduce the opportunity for drug interactions reaching patients by addressing all areas of the medication-use process and not relying solely on the effectiveness of alerts when orders are entered into electronic health records. (Pa Pat Saf Advis 2016 Dec;13[4]:137-148.)

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More Alerts

Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. For example, perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic physician order entry with decision support