Medication errors are among the most common and potentially preventable types of medical errors, accounting for more deaths than motor vehicle accidents, breast cancer, or HIV, and an annual cost of $17 to 29 billion. The elderly are particularly at risk for such complications. The highest risk drugs include anticoagulants, anticonvulsants, antimicrobials, and digoxin. The most frequent serious adverse outcomes include bleeding and acute renal failure. Medication errors can occur anywhere in the medication use process, including diagnosis, prescribing, dispensing, administering, ingesting, and monitoring. Sources of medication errors are quite varied. Among health care professionals, factors such as work stress, distractions, interruptions, inadequate training, fragmented information, or information overload may increase the risk of committing errors, such as prescribing the wrong drug or dose, or omitting needed action in the course of delivery of care, such as failing to properly monitor the use of nephrotoxic drugs or anticoagulants. Among patients, factors such as advanced age, frailty, cultural or literacy barriers, mental illness or incapacity, or lack of adequate social support may contribute to poor adherence with a specified therapeutic regimen. Poor adherence accounts for almost a quarter of all hospital admissions attributed to drugs, and can take the form of overuse, underuse, or erratic use of the drug. Building on its 20 years of experience studying adverse drug reactions and other medication safety problems, the University of Pennsylvania proposes a Center of Excellence for Patient Safety Research and Practice. The proposed Center will re-focus this large past experience on the expansion of this patient safety knowledge base through multidisciplinary research and education programs that are designed to identify and implement systems approaches to reducing error in the use of medications. In particular, we propose a program that will combine investigators in pharmacoepidemiology, health services research, biostatistics, occupational medicine, sociology, psychology, and economics to address a theme of """"""""Improving Patient Safety Through Reduction of Errors in the Medication Use Process."""""""" The program will be composed of four projects and four cores, based at the University of Pennsylvania and linked to the government of the State of Pennsylvania and to the network of Centers for Education and Research in Therapeutics. Each of the four cores will serve the four projects, in such a way as to maximize quality and efficiency simultaneously. Project 1 will study patient and system factors that are predictive of hospitalizations due to dose-related medication errors among elderly individuals taking specific high-risk drugs (warfarin, phenytoin, and digoxin), using a State-run population-based pharmaceutical benefit program. Project 2 will study human and medical practice factors as predictors of poor adherence to warfarin therapy in an anticoagulation clinic setting created as a systems approach to prevent medication errors. Project 3 will study medication errors as causes of preventable acute renal failure in the inpatient setting, despite the existence of a pharmacokinetic monitoring service created to prevent such problems. Project 4 will study conditions that lead to medication errors among physicians, with emphasis on work conditions that increase stress, such as workload, schedules, work organization, shifts, and patient/staff ratios. Core A will be an administrative core, responsible for coordination. Core B will be a data collection core, responsible for all field activities. Core C will be a biostatistics and data management core, responsible for data entry, management, and analysis. Core D will be a dissemination core, responsible for an extensive dissemination program, as the results of the program emerge.
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