BackgroundThere is a high degree of variability in assessing the preventability of adverse drug events, limiting the ability to compare rates of preventable adverse drug events across different studies. We compared three methods for determining preventability of adverse drug events in emergency department patients and explored their strengths and weaknesses.MethodsThis mixed-methods study enrolled emergency department patients diagnosed with at least one adverse drug event from three prior prospective studies. A clinical pharmacist and physician reviewed the medical and research records of all patients, and independently rated each event’s preventability using a “best practice-based” approach, an “error-based” approach, and an “algorithm-based” approach. Raters discussed discordant ratings until reaching consensus. We assessed the inter-rater agreement between clinicians using the same assessment method, and between different assessment methods using Cohen’s kappa with 95% confidence intervals (95% CI). Qualitative researchers observed discussions, took field notes, and reviewed free text comments made by clinicians in a “comment” box in the data collection form. We developed a coding structure and iteratively analyzed qualitative data for emerging themes regarding the application of each preventability assessment method using NVivo.ResultsAmong 1356 adverse drug events, a best practice-based approach rated 64.1% (95% CI: 61.5–66.6%) of events as preventable, an error-based approach rated 64.3% (95% CI: 61.8–66.9%) of events as preventable, and an algorithm-based approach rated 68.8% (95% CI: 66.1–71.1%) of events as preventable. When applying the same method, the inter-rater agreement between clinicians was 0.53 (95% CI: 0.48–0.59), 0.55 (95%CI: 0.50–0.60) and 0.55 (95% CI: 0.49–0.55) for the best practice-, error-, and algorithm-based approaches, respectively. The inter-rater agreement between different assessment methods using consensus ratings for each ranged between 0.88 (95% CI 0.85–0.91) and 0.99 (95% CI 0.98–1.00). Compared to a best practice-based assessment, clinicians believed the algorithm-based assessment was too rigid. It did not account for the complexities of and variations in clinical practice, and frequently was too definitive when assigning preventability ratings.ConclusionThere was good agreement between all three methods of determining the preventability of adverse drug events. However, clinicians found the algorithmic approach constraining, and preferred a best practice-based assessment method.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0617-4) contains supplementary material, which is available to authorized users.
A dverse drug events are a leading cause of emergency department visits and unplanned hospital admissions in Canada 1-3 and a key focus of patient safety initiatives. 4 In 2017, the World Health Organization called for a commitment to reduce severe, avoidable medication-related harms by 50% over the next 5 years. 5 In the United States, the National Action Plan for Adverse Drug Event Prevention called for coordinated efforts in surveillance, oversight and research to develop effective evidence-based strategies to reduce adverse drug events. 6 Identifying system-level weaknesses that contribute to adverse drug events may allow us to target a broader range of events, develop and evaluate innovative system-level interventions, understand why previous prevention efforts have had limited success, and develop new metrics for evaluation. 5 Preliminary studies suggest that unintentional re-exposures to culprit or high-risk medications represent a safety risk. 7-9 However, this evidence is limited, and repeat adverse drug events are poorly understood. If repeat adverse drug events are common, they are likely to warrant new systems-level approaches for prevention. To date, health information technologies have focused on improving clinician adherence to treatment and monitoring guidelines,
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