Description of the condition
Medication-related (drug-related) adverse events in primary care represent an important cause of mortality and hospital admissions (Howard 2003). Medication-related adverse events could be the result of patients either experiencing adverse events (not usually preventable) or as a result of drug administration or medication errors (usually preventable) (Ioannidis 2001).
According to Edwards 2000, adverse drug reactions can be defined as "an appreciably harmful or unpleasant reaction resulting from an intervention related to the use of a medicinal product". Medication errors on the other hand, are mostly preventable. A medication error is defined by Ferner 2006 as "a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient". They are mainly due to either negligence or prescribing errors. A reduction of these types of prescribing errors has been a high priority for healthcare policy in order to improve the safety profile of the healthcare delivery system (Howard 2003; Soe 2013).
A prospective cohort study has shown that within four weeks of receiving a primary care prescription, 25% of patients experience an adverse drug event, 11% of which are judged preventable (Gandhi 2003). A systematic review and meta-analysis by Winterstein 2002 reported that a median 7.1% (inter-quartile range 5.7% to 16.2%) of hospital admissions result from drug-related problems, of which 59% were considered preventable (i.e. attributable to error), while Howard 2007 reported a median of 3.7% of hospital admissions were preventable and drug-related. Improving patient safety is, as a consequence, now a government priority in many economically developed and underdeveloped countries, including the United Kingdom (UK), the United States (US) and five African countries (Brown 2008; WHO 2004).
Description of the intervention
In this review we will examine interventions in primary care to reduce preventable medication errors that result in hospital admissions, mortality and emergency department visits. The three main types of interventions we will examine include: professional, organisational and structural interventions as described by the Cochrane Effective Practice and Organisation of Care (EPOC) Group (EPOC 2013a). We will use these interventions for any type of population, irrespective of their characteristics.
How the intervention might work
The three main interventions, mentioned above, will use different approaches to achieve a reduction in medication errors that lead to hospital admissions, mortality and emergency department visits. Professional interventions include continuing education and quality assurance interventions that provide educational interventions for practitioners or patients, such as teaching the use of structured assessments with general practitioners. Organisational interventions include revision of professional roles (e.g. nurse- or pharmacist-led chronic disease clinics and nurse prescribing) and revision of clinical multidisciplinary teams (e.g. pharmacist-managed medication reviews). Such interventions aim at engaging workers in the management of risk to increase patient safety. Structural interventions include the presence and organisation of quality monitoring services. Examples of these interventions include structural approaches such as social, economic, and political interventions that can improve public health outcomes by increasing the willingness and ability of individuals to practice prevention. Together, the three types of interventions will address the various stakeholders involved in providing health care to individuals in primary care (Benning 2011).
Why it is important to do this review
To date, there is little information on those types of interventions mentioned above, aimed at reducing preventable medication-related adverse events in primary care due to errors. A review undertaken by Ioannidis 2001 addressed interventions of all types of medical errors in both primary and secondary care. It highlighted the complexity involved in studying those types of interventions aimed at minimising errors in healthcare delivery. Other reviews by Durieux 2012 and O'Brien 2008 focused on interventions to improve professional practice and healthcare outcomes, including prescribing. A review by Royal 2006 found that there was little evidence to support pharmacist-led medication interventions as being effective in reducing hospital admissions. None of these reviews have focused on other types of interventions such as professional, organisational and structural that could possibly reduce medication errors in the primary care setting.
Given that preventable medication errors in primary care are associated with hospital admissions, mortality and emergency department visits, it is important to know whether there are any interventions that have been found to be effective in reducing the occurrence of these outcomes. While members of our team published a related systematic review on this topic (Royal 2006), there has been no Cochrane systematic review of interventions aimed at reducing the incidence of preventable medication errors that lead to hospital admissions, mortality and emergency department visits.