Fairview medication error reports involving insulin climbed 34.6 percent from 2006; 17.5 percent of insulin-related errors resulted in an adverse drug event, according to a new report.

The report shows 651 error reports systemwide in 2007, or 20.9 percent of all reported errors, involve the high-hazard drug classes of anti-diabetic agents, narcotics and anticoagulants (see below) according to Steve Meisel, PharmD, Fairview system director, medication safety. "Errors involving these high-hazard drugs are twice as likely to cause patients harm," he says.

Forty percent of hypoglycemic adverse drug events involved quinolone antibiotics. Meisel recommends against using them in diabetic patients unless there are no other suitable antibiotics. Other factors contributing to hypoglycemic events include changing renal status or diet and failure to adhere to protocols.

Efforts to reduce errors and adverse drug events will be implemented at the care system level. "Each site will look at data and identify why errors and adverse events are happening at that site and develop strategies to address them," says Meisel.

A "medication error" is any unintended act of omission or commission involving a medication. An "adverse drug event" is any injury caused by medical care involving medication use. An error may or may not lead

to an adverse drug event, and an adverse drug event may or may not involve an error.

Errors of omission (dose scheduled, but not administered) represent the most common error at 29 percent, followed by doses given at the wrong time (19 percent) and at the wrong dose (16 percent).

Fairview staff detected 274 adverse drug events across seven hospitals using real-time "triggers" (see box)-one event every 1.3 days. Almost 71 percent of adverse drug events involved anti-diabetic agents, while 17.5 percent involved narcotics.

For more information, contact Meisel, 612-672-7061, smeisel1@fairview.org.

Fairview adopted the following indicator of adverse drug events in January 2007. Staff conducts a real-time review of a series of "triggers":

• Naloxone use (indicating an adverse sedative event)
• Flumezenil use (indicating an adverse sedative event)
• Blood sugar less than or equal to 40 mg/dL (anti-diabetics)
• INR more than or equal to 6 (warfarin)
• PTT more than or equal to 200 (heparin)

While triggers alert staff to possible adverse drug events, the triggers may not have been associated with the drug or an adverse event.

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