Frequency, consequences and prevention of adverse drug events

Iatrogenic injuries are important because they are frequent and many may be preventable; those caused by therapeutic drugs are among the most frequent. While medication errors are common, most have little potential for harm. However, some errors, such as giving a patient a drug to which they have a known allergy, are more likely to cause injury. Error theory provides insights into the changes required to reduce medication error injury rates. Data from the Adverse Drug Event (ADE) Prevention study suggest that most serious errors occur at the ordering and dispensing stages, while another, smaller, proportion occur at the administration stage. These data suggest that physician computer-order entry, where physicians write orders on-line with decision support, including patient-specific information and alerts about potential problems, has the potential to significantly reduce the number of serious medication errors.