Dynamic Chiropractic - April 22, 1996, Volume 14, Issue 09

Page printed from:

How Did It Happen?

A recent study found "that 6.5% of adult nonobstetrical patients admitted to two teaching hospitals suffered an ADE (adverse drug event)"; that "most errors occurred in the physician ordering (39%)."

Even more interesting are the "proximal causes" of the ordering errors by the physicians:

pie chart (finally)

Lack of Knowledge about Drug -- 36% (red)
Lack of Information on Patient -- 24% (orange)
Rules Violation -- 19% (yellow)
Slips & Memory Lapses -- 11% (green)
Inadequate Monitoring -- 8% (blue)
Other -- 2% (sand)

---------------------- SOURCE: Leape LL, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.