Identifying medication misadventures: poor agreement among medical record, physician, nurse, and patient reports

Study Objective. To analyze and compare four different methods of detecting medication misadventures in order to determine the optimal system for reporting clinically observed medication misadventures. Design. Prospective cohort study. Setting. Forty-eight-bed general internal medicine inpatient ward at a large academic teaching hospital with a decentralized pharmacy system. Patients. One hundred twenty-six patients (54% male, mean age 54 yrs) with 133 consecutive admissions to the ward (mean length of stay 7.8 days) over an 8–week period from December 2001–February 2002. Intervention. Medication misadventures were detected by four methods: house staff (resident physicians) report during their morning conference, nursing report during shift change, patient report at the discharge interview, and standardized medical record review. All methods of reporting medication misadventures were compared with the hospital's existing electronic medication misadventure reporting system. Measurements and Main Results. Overall, 63 patients (47% of 133 admissions) experienced at least one medication misadventure. Thirty-seven adverse drug events (ADEs) and 69 medication errors were observed over 1035 patient bed-days. Little overlap was noted among the four intervention methods, with nearly 80% of all 106 events detected by only a single method (medical record review 51% [54 events], patient interview 11% [12], house-staff report 9% [10], nurse report 8% [9]). Of the 37 ADEs, 6 (16%) were due to medication errors and 10 (27%) were preventable. Of five life-threatening ADEs, all were preventable, and all were reported in the medical record and the electronic reporting system; however, only two were reported by a nurse, two by a resident physician, and one by a patient. Conclusion. Little overlap was noted among the individual medication misadventure reporting methods, suggesting the need to use multiple complementary methods to identify medication misadventures in hospitalized patients. These findings have important implications for development of surveillance systems, design of prevention initiatives, and future medication safety research.