Preventable adverse drug events causing hospitalization: Identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study

Background: To identify root causes of preventable adverse drug events contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community. Methods: Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported. Results: Most common pADE-related medical conditions: Chronic obstructive pulmonary disease (COPD)/asthma (13.5%) bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%), pneumonia (5%). Most common root causes were: providers not confirming that patient/family: understands information given (29.2%), how a medication helps them/addressing concerns (16.7%), how to identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%), absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented. Interpretation: To prevent pADEs providers need to confirm that patients/families understand: information given, how a medication helps them, how to recognize and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient’s/families’ medication use and monitoring competency.研究背景：本研究旨在明确可预防性药物不良事件（preventable adverse drug events, pADEs）导致患者住院的根本原因，制定可识别患者/家属与医疗人员可采取的干预措施的核心宣教内容，以预防常见pADEs，并构建面向社区的监测学习系统。研究方法：采用横断面观察性研究设计；共访谈120名患者及家属、61名相关医疗人员，随后开展根本原因分析，以此制定核心学习宣教内容，并设计电子报告工具。本研究报告了最常见的与pADEs相关的临床病症及其根本原因，以及整个研究队列中最常见的pADEs根本原因。研究结果：最常见的与pADEs相关的临床病症依次为：慢性阻塞性肺疾病（COPD）/哮喘（13.5%）、出血（12.5%）、低血压（12%）、心力衰竭（10%）、急性肾损伤（5%）、肺炎（5%）。最常见的pADEs根本原因包括：医疗人员未确认患者/家属理解所告知的信息（29.2%）、未明确药物的作用机制/未解答患者顾虑（16.7%）、未指导患者识别药物疗效（14.1%）或药物不良反应（23.3%）；未指导患者进行药物调整操作（7.5%）、缺乏疾病急性期管理方案（12.5%），以及未制定辅助患者应对临床状态变化的其他行动计划（10.8%）；医疗人员未评估患者/家属的药物使用与监测能力（19.2%）。本研究共制定10条核心学习宣教内容，并上线了pADEs监测学习系统。研究解读：为预防pADEs，医疗人员需确认患者/家属充分理解以下内容：所告知的医疗信息、药物的作用机制、如何识别并应对药物不良反应、如何进行药物调整操作以及遵循既定行动计划；同时医疗人员应评估患者/家属的药物使用与监测能力。