Medication errors dramatically reduced in patients with kidney disease

A first of its kind study has shown a dramatic reduction in medication errors in patients with chronic kidney disease when Kaiser Permanente Colorado researchers teamed with pharmacists to use a computerized system to electronically screen prescriptions for unsafe medication orders.

This simple alert reduced medication errors by 41 percent, and the decrease in errors was sustained for more than 15 months. The system further allowed pharmacists to work to correct medication orders based on a patient's kidney function.

"Medication errors are an important problem in the U.S. today," said David Magid, M.D., lead researcher on the Improving Medication Safety Project. "It's estimated that medication errors cost more than $2 billion annually and are responsible for up to 19 percent of injuries in hospitalized patients. What this study shows is that it's important to consider every step of the care process to best protect patients from possible harm."

In this study, more than 16,000 patients with chronic kidney disease were monitored for potential harmful medication orders. Chronic kidney disease (CKD) is a condition that occurs when the kidneys cannot remove waste or maintain the proper fluid and chemical balances in the body. When kidneys are not working properly, waste products build up and become poisonous to the body. Many medications are eliminated from the body by the kidney. When the medication dose is not properly adjusted in patients with kidney disease the risk of serious side effects increases. The most common causes of CKD are diseases such as diabetes and high blood pressure that damage the blood vessels that supply the kidneys. In this project, the automated tool alerted pharmacists to the possibility of an unsafe medication order and stopped the prescription from being filled. The pharmacist then consulted with the prescribing physician on a new course of treatment.


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