357 Detectability of medication errors in older people prior to potentially preventable admissions TEXT BOX Detectability of medication errors (MEs) during in-hospital medication review: three theoretical examples. • Example 1 – ME not present A patient was admitted with electrolyte disturbances, which were adjudicated as overuse of furosemide for ankle oedema (wrong indication). At the time of the in-hospital medication review, no loop diuretics were present. Consequently, this ME could not have been detected during the in-hospital medication review. • Example 2 – ME present, detected by STOPP/START A patient was admitted with an exacerbation of systolic heart failure, adjudicated as being secondary to the underuse of an ACE inhibitor. At the time of the in-hospital medication review, a START signal to initiate an ACE inhibitor for systolic heart failure was generated (START A6). Either this signal was considered not applicable by the pharmacotherapy team (e.g. considered contraindicated due to persistent hypotension) or a recommendation to initiate an ACE inhibitor was not implemented. • Example 3 – ME present, not detected by STOPP/START A patient with atrial fibrillation was admitted with gastrointestinal bleeding, which was adjudicated as misuse of a direct oral anticoagulant in supratherapeutic (unadjusted) dosage with concomitant decreased renal function. At the time of the in-hospital medication review, renal function was 40 ml/min/1.73m2, and no STOPP signal was generated. The pharmacotherapy team recommended a dose adjustment (i.e., non-STOPP/START-based recommendation). However, either this recommendation was not implemented by the attending physician (either intentionally because renal function recovered to >50 ml/min/1.73m2 or unintentionally) or the implemented dose adjustment did not persist (i.e., the dosage prior to admission was re-prescribed after discharge). Results Study population One fifth of OPERAM intervention patients (n = 211, 21.9%, N = 963) experienced their first DRA within the year following the in-hospital medication review. A total of 84 DRAs in 963 intervention patients (8.7%) were adjudicated as potentially preventable and were related to 92 MEs. Fifteen MEs in twelve OPERAM intervention patients were excluded from analysis of this substudy due to missing data (no intervention performed, n = 6; missing data on medical conditions at the time of the in-hospital medication review, n = 6; missing data on generated STOPP/START signals, n = 3). A total of 77 MEs occurring in 72 4
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