Adverse Drug Event 1

Adverse Drug Event

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An adverse drug event (ADE) is described as damage to a patient due to medication

exposure. As with the more broad term adverse event, there is not always a mistake or poor
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quality of care in the incidence of an ADE (Charan, 2021). Potential adverse drug events arise

from a pharmaceutical mistake reaching the patient and causing damage to a certain degree

(Ramia, 2021). Approximately 50% of ADEs are usually considered to be avoidable. Medicine

mistakes which do not cause any damage—before or due to luck—are frequently termed

prospective ADEs since they are caught before reaching the patient (Urman, 2021). An

improbable ADE is one in which the patient has had a drug that might have been minimized, but

not fully avoidable (Shah, 2021). In the end, even when drugs are prescribed and properly given,

a certain proportion of patients suffer ADEs; these are termed adverse responses to medicines or

unavoidable ADE and are often known as adverse effects.

Heparin, for example, is regarded one of the greatest risk medicines for intravenous

anticoagulants in the hospital environment (Kaur, 2021). Safe use of heparin needs weight-based

dosage and regular monitoring of blood coagulation testing to prevent bleeding problems when

the dose is too high or risk coagulation if the dose is insufficient (Bhardwaj, 2021). The usage of

heparin if an improper dosage of heparin is prescribed by a medical practitioner that is regarded a

pharmaceutical error even if a pharmacist detects the problem before the dose is given (Urman,

2021). If the wrong dosage was given but the patient had no clinical effects, this would be a

possible ADE. If an overly high dose was given, the over dosage was seen via aberrant

laboratory findings, but a blood problem was encountered by physicians who did not react

properly (Urman, 2021). In other words, early identification may have decreased the patient's

degree of damage.

Underlying drug events are among the most frequent avoidable adverse events in all care

settings, mainly because to the extensive use of prescriptions and non-prescription medicines

(Kaur, 2021). Clinicians have access to more than 10,000 prescription medicines and over a third
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of people in the US take 5 medicines or more (Kaur, 2021). ADEs account for over 700,000 trips

to emergencies and 100,000 hospitals per year. Almost 5% of hospitalized patients have an ADE

and become one of the most frequent kinds of hospital mistakes (Kaur, 2021). The significant

rise in fatalities caused by opioid drugs, primarily outside of the hospital, shows that ambulatory

patients may suffer ADEs at even greater rates (Gammal, 2021). Care transitions are also a well-

documented cause of avoidable drug harm.

Ways through which ADEs can be prevented include:

1. Ordering: the medicine and dosage, frequency and duration must be chosen by the

physician.

2. Transcription: an intermediary in a paper-based system, a hospital staff member, or a

pharmacist or a pharmacy technician in the ambulatory environment must properly read

and understand the prescription.

3. Dispensing: the pharmacist must check for interactions and allergies between drugs and

allergies, then release the right amount of the medicine in the proper form.

4. Administration: The appropriate medication should be administered at the appropriate

time to the appropriate patient (Gammal, 2021). This is usually the duty of nurses or

other trained personnel in hospitals or in long-term care environments; the obligation for

ambulatory treatment is with patients or cares.

A clinical case approach clearly emphasizes significant diversity among RCA and FMEA

(Haque, 2021). Consider a 75-year-old patient who has received an urgent abdominal discovery

that requires operation (Zeenny, 2021). The patient is a smoker with type 2 diabetes and an
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admission blood sugar of 465, but no indication of DKA is seen. She usually takes an oral

diabetic hypoglycemic and an ACE high blood pressure inhibitor but no additional medicines

(Seger, 2021). She is brought to the OR emerging where operation seems to be going well and

referred to the ICU after surgery. Her blood glucose then fluctuates between 260 and 370 and is

"managed" by insulin on a sliding scale (Gammal, 2021). Unfortunately, she has MI and

developed a surgical wounds infection within 18 hours after surgery 4 days after the surgery. She

finally dies of sepsis.

An RCA of this case may show causes such as a lack of pre-operative usage of a beta-blocker

and a failure to administer IV insulin to reduce your blood sugars to 80-110 (Salameh, 2021).

While the root cause of this bad result may be identified, an RCA is restricted by its hindsight

and the labor-intensive character of the research, which may or may not have wide applicability,

since it is a detailed examination of one instance (Alobaidly, 2021). However, the RCA's have

the beneficial benefits of establishing cooperation and identifying necessary adjustments and

may promote a culture of patient safety when done impartially without assigning any blame.

FMEA offers a new strategy and tries to avoid failure proactively (Alobaidly, 2021). It is a

technique of systematic identification and prevention before product and process problems occur.

For example, FMEA's approach would help to investigate the intense insulin treatment procedure

in order to obtain a thorough control of glucose in ICU (Salameh, 2021). Hypoglycemia is a

major danger in attaining tight glucose control in the range of 80–110. Common problems of

administering insulin include mistakes in administration and computation leading to a 10-fold

insulin dosage differential (Salameh, 2021). Additional administration parameters such as the

kind of IV tubing and how the IV tubing is prepared may have an important bearing on the

quantity of insulin given to the patient and therefore on the glucose levels (Gammal, 2021).
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When an insufficient solution is pumped into the tube for a few hours, the patient may get saline

rather than insulin and the consequence is that glucose levels are higher than anticipated and

insulin titration is at higher dosages (Gammal, 2021). The consequence is an unusually low level

of glucose many hours later. Once such causes of failure are recognized, an unsafe system may

be developed, thereby reducing the likelihood of failures. The FMEA/RCA healthcare disciplines

comprise nursing, mini-first care, medicines and pharmaceuticals, officially trained in a single

NHS Scotland territorial health board.

References
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Charan, J., Kaur, R. J., Bhardwaj, P., Haque, M., Sharma, P., Misra, S., & Godman, B. (2021).

Rapid review of suspected adverse drug events due to remdesivir in the WHO database;

findings and implications. Expert review of clinical pharmacology, 14(1), 95-103.

Ramia, E., Zeenny, R. M., Hallit, S., & Salameh, P. (2021). A population-based study of self-

reported adverse drug events among Lebanese outpatients. Scientific Reports, 11(1), 1-10.

Urman, R. D., Seger, D. L., Fiskio, J. M., Neville, B. A., Harry, E. M., Weiner, S. G., ... &

Schnipper, J. L. (2021). The burden of opioid-related adverse drug events on hospitalized

previously opioid-free surgical patients. Journal of patient safety, 17(2), e76-e83.

Shah, S. N., Gammal, R. S., Amato, M. G., Alobaidly, M., Reyes, D. D., Hasan, S., ... & Bates,

D. W. (2021). Clinical utility of pharmacogenomic data collected by a health-system

Biobank to predict and prevent adverse drug events. Drug Safety, 44(5), 601-607.