Errors and transplant patients

Patients recovering from organ transplants run a high risk of medication errors that can land them back in the hospital, according to a Yale study published in the Archives of Surgery in March.

In the years after surgery, liver, kidney or pancreas transplant recipients took an average of 10.9 medications. The study found 149 errors occurring in 93 patients, with 32 percent resulting in invasive procedures, rejection or failed transplants.

In more than half the cases—56 percent—patients didn’t follow instructions. In other cases, pharmacists substituted generic for brand-name medications or declined to provide the proper medications out of concerns about adverse drug interactions.

“Once the prescription is ordered, we have no routine feedback from the patient, pharmacy or insurer to know whether the medication is being used,” said lead author Amy L. Friedman, M.D., associate professor of surgery. Every encounter with a patient should be viewed as an opportunity to clarify which medications are being taken.