Table 4

Drug classes most frequently associated with preventable drug related admissions due to monitoring problems

British National Formulary class	Adverse drug event	Problem	Number of cases
*If a drug related admission involves more than one causative drug it may be recorded more than once in the table.
†Further details on “other” drug categories are available on the QSHC website (www.qshc.com/supplemental).
Loop diuretics	Overdiuresis causing dehydration ± renal failure ± electrolyte imbalance	Failure to monitor fluid balance, renal function, electrolytes etc*	7
	Congestive cardiac failure	Failure to monitor following cessation of angiotensin converting enzyme inhibitor and diuretics*	1
	Dizziness	Unnecessary polypharmacy*	1
	Hyponatraemia	Failure to check electrolytes	1
		Subtotal	10
Potassium sparing diuretics	Overdiuresis causing dehydration ± renal failure ± electrolyte imbalance	Failure to monitor fluid balance, renal function, electrolytes etc*	5
	Hyponatraemia		1
	Hyperkalaemia		1
	Dizziness	Unnecessary polypharmacy*	1
		Subtotal	8
Sulphonylureas	Hypoglycaemia	Failure to monitor blood sugar and renal function	5
	Hyperglycaemia	Failure to monitor blood sugar	3
		Subtotal	8
Cardiac glycosides	Digoxin toxicity	Failure to monitor renal function and/or digoxin levels at least annually.	4
	Fast atrial fibrillation	Failure to ensure that digoxin levels were therapeutic	1
	Dizziness	Unnecessary polypharmacy*	1
		Subtotal	6
Thiazide and related diuretics	Overdiuresis causing dehydration ± renal failure ± electrolyte imbalance	Failure to monitor fluid balance, renal function, electrolytes etc.*	4
	Hypotension ± hyponatraemia		2
		Subtotal	6
Antiepileptics	Toxicity	Failure to monitor phenytoin levels	3
		Failure to review patient after increasing carbamazepine dose	1
	Fitting	Failure to monitor phenytoin levels	1
		Subtotal	5
Other			27†