A Wake-up Call: Vancouver Study Reveals Harmful Medication Re-Exposure Could be Avoided with New Approaches

A Wake-up Call: Vancouver Study Reveals Harmful Medication Re-Exposure Could be Avoided with New Approaches

The Vancouver Coastal Health Research Institute-led study reports that a key finding of a recent study reveals adverse drug events could be avoided by sharing patients’ medication histories and previous harmful medication exposures among various health care facilities.

Led by Dr. Corinne Hohl, the study results are a wake-up call to urgently find new approaches to better protect the health and safety of patients. Dr. Hohl’s study examined when medications were incorrectly re-prescribed and caused an unintended effect, reports the University of British Columbia.

The Study

The Vancouver-based team utilized patient recorded chart history at Vancouver General, St. Paul’s and Lions Gate hospitals. They tracked first occurrences of adverse drug events coupled with repeat events from the same medication or medication class.

The team found that among the almost 13,000 adult patients in the study, 1,178 were diagnosed with 1,296 adverse drug events. Of these, more than 33% had a repeat adverse drug event, and almost 40% of those patients were admitted to the hospital after being discharged from the emergency department.

The study revealed that approximately 75% of the repeat adverse drug events could have been prevented through better monitoring and communications.


A first step toward reducing the number of adverse drug events would be to boost reporting and recording procedures. Adverse drug events and other important medical information should live in a centralized database that can be accessed by all members of a patient’s care team, including physicians, nurses and pharmacists.

Clinicians across the care continuum who access the centralized database could review a patient’s medication and adverse drug event history. They could enter their recommended course of treatment, and an alert would appear if the medication to be dispensed was associated with a previous adverse drug event in the patient’s file. Each year, approximately two million Canadians will arrive at an emergency room department because of an adverse drug event.

In her work as an emergency physician at Vancouver General Hospital, Hohl said she regularly sees repeat adverse drug events to the same medication. In one case, a patient with diabetes and hypertension presented to VGH with angioedema in the form of life-threatening airway swelling. After conducting further investigations, Hohl discovered that he had been re-prescribed a medication that had seen him present to another hospital’s emergency room with angioedema three months prior.

Investigator Comment

Dr. Corinne Hohl reported, “As the medical system improves how we treat and prevent diseases, we may be inadvertently putting patients on medications that previously caused harm, have already been identified as contraindicated, or on wrong medication doses.” She continued, “This research study provides us with clues as to how we can reduce adverse events and their impact on health care by establishing a centralized and integrated system for reporting and accessing medication-related patient information.”

Lead Research/Investigator

Dr. Corinne Hohl