A surprising number of ED visits involve patients who are presenting because of medication harms, according to a recent analysis.1 Data from 60 EDs for visits during 2017-2019 revealed that an estimated one out of 64 ED visits each year are for acute medication-related harms. “Previous studies of medication safety have focused on harm from medications when taken for therapeutic reasons or harm from specific types of nontherapeutic use,” says Dan Budnitz, MD, MPH, CAPT, USPHS, the study’s lead author and director of the CDC’s Medication Safety Program.2

Budnitz and colleagues examined the number of ED visits that happened when people who took medications for any reason (e.g., prescribed by a clinician, recreational use, or intentional self-harm). When considering all types of medication-related harms, the rate of ED visits was similar for patients age 15-64 years. “What differed was the intended use for medications and the specific medications involved for each age group,” Budnitz reports.

Of the 96,925 cases included in the analysis, 69.1% involved therapeutic use. Medication-related misuse, abuse, or self-harm caused approximately 62% of ED visits for medication-related harms in patients age 15-24 years, but only 22% of visits for patients age 55-64 years. For patients younger than age 45 years, 52.5% of ED visits involved nontherapeutic use.

For children younger than age 5 years, unsupervised medication exposures and therapeutic use of antibiotics were the leading causes of harm. For patients age 15-24 years, misuse, abuse, or self-harm involving alprazolam were to blame. For patients age 25-44 years, it was nontherapeutic use of benzodiazepines. More research is needed on the most effective harm reduction approaches when young and middle-aged adults intentionally misuse benzodiazepines, opioids, and over-the-counter medications. “For example, can screening tools that accurately identify patients who are likely to misuse medications or self-harm with medications be coupled with effective prevention?” Budnitz asks.

For patients age 45 years and older, therapeutic use of anticoagulants and diabetes agents inflicted the most harm. “For older adults, optimizing both the safety and effectiveness of anticoagulants and diabetes medications continues to be a challenge,” Budnitz laments.

New oral anticoagulants (e.g., apixaban and rivaroxaban) carry lower rates of bleeding complications. New diabetes medications (e.g., SGLT2 inhibitors and GLP-1 receptor agonists) carry lower rates of hypoglycemia.3 “Nonetheless, bleeding from anticoagulants and hypoglycemia, especially among older adults, remains the leading cause of acute adverse events leading to ED visits,” Budnitz reports.

Patients experiencing harms from medications present to the ED in many ways. Sometimes, it is apparent, such as changes in mentation; other times, it is more inconspicuous and requires diagnostic tests to pinpoint, says Andrew S. Martin, MSN, RN, CPHRM, patient safety analyst and consultant at ECRI.

“ED clinicians may become anchored on a particular diagnosis and may not always consider medication harm, as medication harm may manifest with similar symptoms as other diagnoses,” Martin observes.

Patients do not always disclose nontherapeutic use of medication to providers. Mary C. Magee, MSN, RN, CPHQ, CPPS, project manager, patient safety analyst, and consultant at ECRI, warns, “this nondisclosure does not alleviate the responsibilities of the ED clinicians to identify acute issues, provide treatment to stabilize the patient, and refer for follow-up, as appropriate.”

REFERENCES

  1. Budnitz DS, Shehab N, Lovegrove MC, et al. US emergency department visits attributed to medication harms, 2017-2019. JAMA 2021;326:1299-1309.
  2. Shehab N, Lovegrove MC, Geller AI, et al. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA 2016;316:2115-2125.
  3. Doyle-Delgado K, Chamberlain JJ, Shubrook JH, et al. Pharmacologic approaches to glycemic treatment of Type 2 diabetes: Synopsis of the 2020 American Diabetes Association’s standards of medical care in diabetes clinical guideline. Ann Intern Med 2020;173:813-821.