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Purpose We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D. Methods In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE. Results We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn’s disease. They were also more likely to have used opioids chronically and at higher daily doses. Conclusion There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population.

Purpose The development and evaluation of an algorithm for detecting potential medication errors due to look-alike/sound-alike (LASA) drug names are described. Summary A computer algorithm that detects potential LASA errors by analyzing medication orders and diagnostic claims data was developed. The algorithm flags a potential error when (1) a medication order is not justified by a diagnosis documented in the patient’s record, (2) another medication whose orthographic similarity to the index drug exceeds a specified threshold exists, and (3) the latter drug has an indication that matches an active documented diagnosis. A review of medication orders and diagnostic claims at a large health system identified cases in which cycloserine was ordered but cyclosporine was the intended treatment. Subsequent review of all cycloserine orders over a 7-year period indicated that 11 of 16 orders were erroneous, prompting placement of an alert regarding the potential for LASA errors involving cycloserine and cyclosporine in the electronic order-entry system. Automated detection and confirmation of LASA errors via chart review can be used retrospectively to identify problematic pairs of drug names and to assess associated error rates within a healthcare system. The same techniques can be used to prevent errors in real time through indication alerts if accurate diagnostic information is available at the time of order entry. Conclusion Automated methods involving the use of medication orders, diagnostic claims, and indications can be used to detect and prevent LASA errors.

Purpose The use of anticoagulant therapy for the prevention and treatment of venous thromboembolism (VTE) and acute coronary syndrome (ACS) among hospital inpatients was evaluated. Methods Medication-use data were retrospectively collected on 1716 patients who received anticoagulants for VTE or ACS at 42 community hospitals during the period April–June 2009; all hospitals in the sample were members of the same large health care organization. Descriptive analyses were performed to characterize anticoagulant use, patient safety, compliance with national prescribing guidelines, and performance on relevant Joint Commission quality measures. Results The most common indications for anticoagulant use were VTE prophylaxis (67.5% of cases), ACS (13.5% of cases), and VTE treatment (11.9% of cases). The agents most commonly used for VTE prophylaxis were subcutaneous enoxaparin (70% of cases) and subcutaneous unfractionated heparin (UFH). Overall, the anticoagulant regimen used was consistent with national prescribing guidelines in 67.5% of cases; however, rates of appropriate prescribing were lower in subgroups of patients with renal impairment, obesity, or both (63.6%, 42.5%, and 63.6%, respectively). Reported anticoagulant-related adverse events during the study period mainly involved minor or major bleeding, which occurred in 36% and 32% of cases, respectively. Compliance with Joint Commission core measures ranged from 49.1% for core measure VTE-3 (warfarin overlap therapy) to 72.3% for VTE-4 (monitoring of UFH dosages and platelet counts by protocol). Conclusion Among hospitals in a large national health care system, the most common use of anticoagulants in hospitalized patients was for VTE prevention, followed by ACS and VTE treatment. Enoxaparin and UFH were the most commonly used agents for each indication, and the selection and use of anticoagulants were in compliance with national guidelines in the majority of patients for whom those drugs were prescribed.

The implementation of a mandatory assessment of risk for venous thromboembolism (VTE) in a health system's electronic medical record (EMR) and clinical decision-support (CDS) system was evaluated to measure its effect on the use of pharmacologic prophylaxis and the occurrence of VTE and bleeding events.A commercially available CDS system was used in designing the automated CDS intervention. During computerized order entry, the system delivered alerts prompting clinician risk assessment and also delivered alerts under circumstances suggesting less-than-optimal prophylaxis. Rates of pharmacologic prophylaxis, clinically diagnosed hospital-acquired VTE, and hospital-acquired bleeding events were measured during one year before and one year after implementation.After adjustment for patient age, sex, and high-risk comorbidities, the data showed a postimplementation increase in the percentage of patients who received pharmacologic prophylaxis at some time during their admission from 25.9% to 36.8% (p0.001). The rate of VTE for the entire hospital did not change significantly, but a significant reduction among patients on medical units was observed, from 0.55% to 0.33% (p = 0.02). There was no increase in either major or minor bleeding events.Without increasing the risk of bleeding, a CDS system requiring clinicians to document VTE risk assessment in the EMR promoted improved rates of pharmacologic prophylaxis at any time during an admission and a decreased risk of VTE in general medical patients but not all adult patients.