Appendix – Adverse Drug Events
Preventable or Effect¶
Severity*
Prescription
Ameliorable?
changes**
1 Patient discharged from hospital with diagnosis of non-cardiac
Neither
More than Significant
Beta-blocker
chest pain; nevertheless, the dose of the beta-blocker was
one day of
dose increased
increased. The patient had non-specific symptoms that resolved
symptoms
when the medication was changed to pre-admission doses.
2 Patient with known seizure disorder, started on an antibiotic
Neither
NonLifeAntibiotic
known to potentially alter levels of anti-epileptic drugs. No
permanent threatening
started
monitoring performed in or out of hospital and the patient
disability
presented with generalized seizure shortly following discharge.
Blood levels of anti-epileptic drugs sub-therapeutic.
3 Patient developed life-threatening electrolyte abnormality and
Preventable
NonLifeSpironolactone
severe symptoms after receiving a medication, which often
permanent threatening
added
causes this problem, no monitoring done for two weeks.
disability
4 Patient experienced nausea as a result of antibiotics prescribed
Ameliorable More than Significant
Antibiotics
for urinary tract infection. Patient’s symptoms were not
one day of
started
addressed by follow-up care.
symptoms
5 Patient prescribed very high doses of corticosteroid and
Ameliorable More than Significant Corticosteroid
developed a generalized anxiety reaction. Patient’s symptoms
one day of
started
were not addressed by follow-up care.
symptoms
6 Patient prescribed narcotics with no teaching about constipating
Preventable More than
Serious
Narcotics
effects or co-prescription of stool softener. After several days of
one day of
started
progressive, the patient came to ER for treatment of severe
symptoms
constipation and vomiting. The patient responded to IV fluids,
enemas and anti-emetics.
7 Patient developed nausea, diarrhea and arthralgia during
Neither
More than Significant
Antibiotics
antibiotic use. Symptoms resolved with discontinuation of
one day of
started
medication.
symptoms
8 Patient with renal insufficiency prescribed a beta-blocker and a
Neither
NonLifeBeta-blocker
calcium channel blocker concomitantly at discharge. Readmitted
permanent threatening
started
with life-threatening bradycardia.
disability
9 Patient discharged on corticosteroid and developed
Ameliorable More than Significant Corticosteroid
sleeplessness, poor glycemic control, polyuria, bilateral ankle
one day of
started
selling and acne. Patient’s symptoms were not addressed by
symptoms
follow-up care.
10 Patient developed candida infection as a result of antibiotic use.
Neither
More than Significant
Antibiotic
one day of
started
symptoms
11 Patient developed a rash secondary to a medication. Patient’s
Ameliorable More than Significant
Beta-blocker
symptoms were not addressed by follow-up care.
one day of
started
symptoms
12 Patient prescribed a beta-blocker at discharge despite a history of Ameliorable More than Significant
Beta-blocker
asthma. Patient not warned of potential side effects; and at home
one day of
started
the patient developed wheezing and coughing. Symptoms
symptoms
resolved with discontinuation of drug.
#
HISTORY
13 Patient developed candida infection as a result of antibiotic use.
The infection spread and therefore the patient went to the ER
without calling the primary care doctor.
14 Patient developed a rash secondary to a medication. Patient’s
symptoms were not addressed by follow-up care.
1
Ameliorable
Ameliorable
More than
one day of
symptoms
More than
one day of
symptoms
Significant
Antibiotic
started
Significant
Antibiotic
started
15 Patient developed non-specific symptoms related to a medication
prescribed in doses greater than the recommended. Patient’s
symptoms were not addressed by follow-up care. But patient
lowered the dose on own with resolution of symptoms.
16 Patient on warfarin discharged with inappropriate dosing of
warfarin and inappropriate follow-up of INR. No bleeding ensued
but INR>10.
Ameliorable
More than
one day of
symptoms
Significant
Preventable
Laboratory
Lifethreatening
17 Patient developed nausea and vomiting secondary to a
medication. Patient’s symptoms were not addressed by follow-up
care.
Ameliorable
One day of
symptoms
18 Patient prescribed caffeine-containing medication, and developed
insomnia. Patient’s symptoms were not addressed by follow-up
care.
19 Patient prescribed narcotics with no teaching about constipating
effects or co-prescription of stool softener. The patient developed
constipation, nausea and poor oral intake.
20 Patient developed a hoarse voice after being discharged on an
inhaled steroid. The patient did not recall being taught about
gargling or rinsing after using the inhaled steroid.
21 Patient developed a rash from a medication.
Ameliorable
More than
one day of
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
Laboratory
22 Patient developed edema on a corticosteroid.
Preventable
Preventable
Neither
Neither
23 Patient on warfarin discharged with inappropriate dosing of
warfarin and inappropriate follow-up of INR. No bleeding ensued
but had to go to the ER for vitamin K injection.
24 Patient developed a cough after an angiotensin-converting
enzyme inhibitor was prescribed. Patient’s symptoms were not
addressed by follow-up care
25 Patient experienced cough because an anti-asthmatic medication
not prescribed at discharge.
Preventable
Ameliorable
Preventable
26 Diarrhea developed post-discharge associated with iron
supplements, which resolved when they were stopped.
Neither
27 Acute interstitial nephritis developed post hospitalization, related
to antibiotic prescribed at discharge. Patient had renal
insufficiency and required kidney biopsy.
28 Patient on cancer treatment did not receive anti-emetic at the
outpatient pharmacy (told that they did not have it in stock). It
took 24 hours to obtain it, during which time the patient had
moderate nausea.
29 Patient sent home on ipratropium and developed dysgeuzia. After
calling doctor and pharmacist told to stop the medication and
symptoms resolved.
30 Patient developed nausea, anorexia, and retching on an
antibiotic. Symptoms persistent for nearly two weeks at which
time antibiotic was stopped and had resolution.
31 Patient was diuresed vigorously, and experienced postural
symptoms. There was no history of falls.
Neither
2
Ameliorable
Neither
Ameliorable
Neither
Proton-pump
inhibitor started
Long term
warfarin, but
new therapeutic
level
Significant
Antibiotic
started
Significant
Significant
Medication
started at
discharge
Narcotics
started
Significant
Fluticasone
inhaler started
Significant
Antibiotic
started
Significant
Corticosteroid
started
Serious
Warfarin started
More than Significant
ACEi started
one day of
symptoms
More than Significant Salbutamol not
one day of
prescribed
symptoms
erroneously
More than Significant
Iron
one day of
supplements
symptoms
started
NonLifeAntibiotic
permanent threatening
started
disability
More than Significant Anti-emetic not
one day of
available
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
Significant
Ipratropium
started
Significant
Antibiotic
started
Significant
Change in
diuretic dose
32 Elderly patient developed constipation after being discharged on
verapamil.
Neither
33 Patient on warfarin discharged with inappropriate dosing of
warfarin and inappropriate follow-up of INR. No bleeding ensued
but INR>8.
34 Patient developed rash at site of low molecular weight heparin
injections after going home.
Preventable
Neither
35 Patient sent home on clonidine for treatment of hypertension.
After discharge the patient could not urinate. The physician was
called and clonidine was discontinued. The problem resolved.
36 Patient sent home on a corticosteroid and subsequently
developed generalized weakness and abdominal bloating.
Problems resolved after prednisone discontinued.
Neither
37 Patient sent home on a corticosteroid and developed insomnia.
Patient’s symptoms were not addressed by follow-up care.
Ameliorable
38 Patient with pain secondary to a newly diagnosed cancer
inappropriately treated at discharge. This pain was well
controlled following an appointment to cancer center and
adjustments in analgesia.
39 Patient on warfarin discharged with inappropriate dosing of
warfarin and inappropriate follow-up of INR. No bleeding ensued
but INR>9.
40 Patient developed skin rash to antibiotic.
Preventable
41 Patient developed serious drug toxicity resulting in permanent
disability caused by intravenous medication given at home that
should have been monitored, but no drug levels were done after
discharge.
42 Patient readmitted for gastritis secondary to concomitant aspirin
and corticosteroid. Symptoms persistent for weeks and not
addressed by follow-up care.
43 Patient developed nausea related to treatment with
metronidazole.
Preventable
Neither
Preventable
Neither
Ameliorable
Neither
More than
one day of
symptoms
Laboratory
Significant
LifeWarfarin started
threatening
More than
one day of
symptoms
More than
one day of
symptoms
More than
one day of
symptoms
Significant
Significant
Corticosteroid
started
More than
one day of
symptoms
More than
one day of
symptoms
Significant
Corticosteroid
started
Serious
Narcotic
therapy started
Significant
Low molecular
weight heparin
started
Clonidine
started
More than
LifeWarfarin started
one day of threatening
symptoms
More than Significant
Antibiotic
one day of
started
symptoms
Permanent
Serious
Antibiotic
disability
started
More than
one day of
symptoms
More than
one day of
symptoms
Nonpermanent
disability
Significant
Corticosteroid
started
Significant
Metronidazole
started
44 Patient discharged on antibiotics and developed diarrhea after
Ameliorable
Serious
going home. Several days later (no intervening follow-up) the
patient returned to the ER with pan-colitis and was readmitted.
The diagnosis was c. difficile colitis.
45 Patient with chronic pain discharged home on multiple
Preventable
NonSerious
benzodiazapines and narcotics. Three weeks later the patient
permanent
was admitted with stupor due to over use of psychotropic
disability
medications.
¶
Effect refers to the duration of symptoms or extent of disability experienced by the patient.
* Severity refers to the subjective assessment of the ADE severity by the physician reviewers.
** Prescription changes refer to changes in prescriptions for the offending medication relative to
the medications the patient was taking before hospitalization. All but one of the ADEs occurred
secondary to a new medication being started or a change in the dose of a medication taken
before the hospitalization.
3
Verapamil
started
Antibiotics
started
Long-term
benzodiazepine
and narcotic
use