Many Outpatients Experience Drug-Related Injuries

While adverse drug events, or injuries caused by drugs, are known to occur among hospitalised patients, such incidents are also common among outpatients, researchers reported this week. In a study of over 600 adult outpatients, investigators found that one out of every four experienced a detrimental health effect from a drug. What's more, nearly 40 percent of these events could have been prevented or greatly reduced in severity or duration.

Few studies have been conducted about drug-related injuries occurring outside the hospital, despite the fact that most people receive prescriptions for drugs to take at home, the researchers note.

In a previous study of hospitalised patients, researchers found that 6.5 percent of patients experienced a drug-related injury - 28 percent of which were preventable. Another study estimated that more than 1 million people were hospitalised in 1994 due to drug-related injuries.

Among outpatients, annual estimates of the proportion affected by drug-related injury have ranged from as low as five percent to as high as 35 percent.

In the current study, a team of Massachusetts researchers surveyed and reviewed the medical records of 661 people who visited two hospital-based and two community-based centres between September 1999 and March 2000. Prescriptions were computerized at one hospital centres and one community centre and handwritten at the other two centres.

"Our goal was to understand how these events might best be prevented, focusing on systems rather than individuals," study author Dr. Tejal Gandhi of Brigham and Women's Hospital in Boston told Reuters Health. Altogether, 25 percent experienced a drug-related injury, 11 percent of which were preventable, Gandhi and colleagues report in Wednesday's issue of The New England Journal of Medicine. Thirteen percent of the injuries were serious, including cases of gastrointestinal bleeding and a slowed heart beat. Two of the serious events were preventable, including the case of an elderly patient who was prescribed an antibiotic to which he or she was known to be allergic.

In fact, 35 percent of the preventable injuries could have been avoided if all of the centres used advanced systems of computerized medication ordering. Such systems perform error-reducing functions including checking the dose of each drug, the report indicates. "Our systems of outpatient prescribing could be substantially improved," Gandhi said. Twenty-eight percent of the problems were ameliorable, meaning that they could have been substantially reduced in severity or duration if different actions had been taken, the report indicates. The majority (63 percent) of these injuries occurred when doctors did not respond to medication-related symptoms, but in 37 percent of cases patient were faulted for not telling their doctor about their symptoms.

"We were surprised by how high the rates were, as compared to the inpatient studies," Gandhi said. "We think this is because we spoke with patients directly rather than relying on the medical chart or administrative data." Depression and high blood pressure drugs, such as serotonin re-uptake inhibitors and beta-blockers, respectively, were often involved in the adverse drug events. Among inpatients, however, sedatives and antibiotics tend to be the drugs most commonly implicated in drug-related injuries, the report indicates. The medications themselves were not to blame for drug-related injury, the researchers note. Rather, patients who were prescribed more medications were more likely to experience an adverse drug event. To reduce the high rates of drug-related injury, Gandhi calls for "strategies' to improve patient-doctor communication, education about side effects, and implementing computerized prescribing."

"Patients should be knowledgeable about their medications, make sure their doctors know all of the medications they are taking, and patients should understand side effects," Gandhi said. Also, the researcher added, "if patients are having problems with their medications, they should know how to contact their physician or doctor's office to report the problem."
Charnicia E. Huggins, Reuters Health, Friday, 18th April 2003
Source: The New England Journal of Medicine 2003;348:1556-1564

CTM COMMENT: Patients should also be knowledgeable of the fact that dependency upon the doctor, his wares and his advice is one of the biggest causes of injury and death today. And what exactly is meant by the following: "The medications themselves were not to blame for drug-related injury, the researchers note. Rather, patients who were prescribed more medications were more likely to experience an adverse drug event."? We appear to have a new line in medical double-meaning. "It wasn't the drugs, Your Honour. It was the drugs." Our previous eclub bulletin highlighted the outcome of a doctors' strike in Israel. The death rate dropped to such an extent that local embalmers began pressing the government to give in to the doctors' pay demands. The embalmers needed their clients back. No double meaning there. Doctors can be very dangerous. Argue that if you can.