View
233
Download
1
Embed Size (px)
Citation preview
Objectives
Goals and Objectives: The goal of this activity is to help providers in all settings develop a better knowledge base from which they can prevent polypharmacy and medication errors.
Upon completion of this activity, the learner will be able to:
Discuss the impact of polypharmacy and medication errors.
List different types and/or risk factors of polypharmacy and medication errors.
Describe potential problems with using medical abbreviations.
Identify the different problems that can be caused by drug names.
Define at-risk behaviors as they relate to polypharmacy and medication errors.
Discuss different ways individuals and organizations can reduce the risk of medication errors.
Explain what should be done if a medication error has occurred.
2
What is Polypharmacy?
Use of multiple medications for the treatment of a
patient's medical conditions
More medication is being used than is clinically
indicated
Inappropriate polypharmacy imposes a substantial
burden of adverse drug events, ill health, disability,
hospitalization, and even death
Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-351.
4
Polypharmacy Risk Factors
Elderly
Multiple comorbid conditions
Recent hospitalization
Multiple physicians
Multiple pharmacies
Inappropriate medication
Poor documentation
5
Healthcare Provider’s Factors
No patient’s medication review on regular basis
Provides unclear, complex or incomplete instructions
No effort to simplify medication regimen
Ordering automatic refills
Lack of knowledge
6
Patient’s Factors
Multiple providers and/or pharmacies
Insisting on taking inappropriate drugs
Inaccurately report meds taken or symptoms
Assumption that all medications needs to be
continued once started
Changes in lifestyle activities
7
Negative Outcomes
Polypharmacy has been shown to increase:
Unnecessary / inappropriate medication prescribing
Risk of drug interactions / adverse drug reactions
Medication nonadherence
Overall drug expenditures
8
Example
85 y/o woman with a prescription of Amitriptyline 50mg at bedtime for insomnia.
Side effects:
Constipation
Urinary Incontinence
Dizziness
Dry mouth
Dry eyes
Possible new medications:
Docusate with senna
Oxybutinin
Eye drops
9
Management of Polypharmacy
Obtain an accurate medication and medical history
Link each prescribed medication to a disease state
Identify medications that are treating side effects
Initiate interventions to ensure adherence
Reconcile medications upon any discharge from
hospital or skilled nursing facility
Prevention
10
“Deprescribing”
Process of tapering or stopping drugs, aimed at
minimizing polypharmacy and improving patient
outcomes
Ascertain all drugs patient is currently taking and why
Consider overall risk of drug-induced harm
Assess each drug for its eligibility to be discontinued
Prioritize drugs for discontinuation
Implement and monitor drug discontinuation regimen
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175:827-34.
11
“Deprescribing” Algorithm
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175:827-34.
12
High Risk Medications
Side Effect Common Causing Drugs Common Treating Drugs
Constipation Tricyclic antidepressants, first-gen
antihistamines, verapamil,
diltiazem, opioid analgesics,
calcium supplementation
- Psyllium
- Docusate / senna
- Lactulose
Insomnia Prednisone, pseudoephedrine,
stimulants, antidepressants,
theophylline
- First-gen antihistamines
- Benzodiazepines
- Zolpidem / zaleplon
Somnolence Antihistamines, benzodiazepines,
gabapentin, opioid analgesics
- Stimulants / caffeine
- Modafinil
Cognitive impairment Oxybutinin, tolterodine,
antihistamines, opioid analgesics,
benzodiazepines
- Donepezil
- Rivastigmine
- Galantamine
- Memantine
Diarrhea Metformin, antidepressants, PPI,
antibiotics
- Loperamide
- Diphenoxylate
13
Recommendations
Use tools to avoid elderly patients exposure:
Beers Criteria:
American Geriatrics Society Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults
START/STOPP Criteria (Pharmacist’s / Prescriber’s
Letter):
Screening Tool to Alert Doctors To Right Treatments (START)
Screening Tool of Older Persons’ Potentially Inappropriate
Prescriptions (STOPP)
14
START/STOPP
Pharmacist’s Letter: Reducing Medication Errors in High-Risk Situations and Populations
15
Definitions
In healthcare, an error has been defined by the IOM as:
the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning)
An error may be an act of commission or an act of omission
A medication error has been defined as:
any error occurring in the medication use process
Institute of Medicine. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004.
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205.
17
Examples
Medication errors can include:
giving a medication to the wrong patient
giving the wrong dose of a medication
not prescribing a medication that was indicated
entering an order for the wrong patient
forgetting to give a medication that was due
Wittich CM, Burkle CM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc. 2014;89:1116–25
18
Pharmacovigilance
Drug Safety (IOM):
science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other medicine-related problem
Adverse Drug Event:
is an adverse outcome that can be attributed, with some degree of probability, to an action of a drug
May or may not be due to a medication error
Adverse drug effects and reactions:
nonpreventable adverse drug events
World Health Organization. Pharmacovigilance: Ensuring the Safe Use of Medicines. Geneva, Switzerland: World Health Organization; 2004:6. WHO Policy Perspectives on Medicines 9.
Aronson JK, Ferner RE. Clarification of terminology in drug safety. Drug Saf. 2005;28(10):851-870.
19
ASHP Categories
American Society of Health-System Pharmacists categorizes medication errors based on:
prescribing
omission
timing
use of an unauthorized drug
improper dosing
wrong dosage form
wrong drug preparation
wrong administration technique
deteriorated drug
monitoring
compliance
ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50(2):305-314.
20
Other Categories
The National Coordinating Council for Medication
Error Reporting and Prevention categorizes the
relationship between error and harm as:
no error (circumstances have the capacity to cause error)
error but no harm
error and harm
error and patient death
National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. www.nccmerp.org/medErrorCatIndex.html.
21
Incidence
Medication errors are the most common type of medical error.
The Institute of Medicine (IOM) estimates 1.5 million preventable medication errors happen in the United States each year
Medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths
Some medication errors cause harm to the patient, most do not
< 1% of medication errors resulted in an adverse drug event
Kohn LT, Corrigan J, Donaldson Molla S; Institute of Medicine Committee on Quality of HealthCare in America. To Err is Human: Building a Safer Health System. National Academy Press; 2000.
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205.
22
Reporting
Voluntary reporting systems used to track medication errors:
US Food and Drug Administration (FDA) MedWatch:
http://www.fda.gov/Safety/MedWatch/
United States Pharmacopeia (USP) and Institute for Safe Medication Practices (ISMP) - Medication Error Reporting Program (MERP):
https://www.ismp.org/errorReporting/reportErrortoISMP.aspx
Quantros, Inc MEDMARX (software)
https://www.medmarx.com/
23
Top Drugs
Top 10 drugs most commonly implicated in drug errors:
insulins, albuterol, morphine, potassium chloride, heparin, cefazolin, furosemide, levofloxacin, and vancomycin
The 5 most commonly implicated drug classes (27.7%):
insulins, opioid-containing analgesics, anticoagulants, amoxicillin-containing agents, and antihistamines/cold remedies.
Vecchione A. USP Drug Safety Review: Top 10 drugs involved in medication errors. Drug Topics website. http://drugtopics.modernmedicine.com. Published December 8, 2003
Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. JAMA.
2006;296(15):1858-1866.
24
Risk Factors
Unapproved abbreviations and illegible handwriting
Look-alike and sound-alike products
Patient risk factors such as age, comorbidities, and
polypharmacy
Decline in renal or hepatic function
Cognitive biases and lack of situational awareness by
health care professionals
25
Pediatric Medication Errors
Inpatient Outpatient
Improper dose / quantity Wrong administration
Omission Improper prescribing
Wrong drug Incorrect dispensing
Prescriber error Issues transmitting
Wrong administration
Wrong time
Drug prepared incorrectly
Wrong dosage form
Wrong route
26
Pediatric Prescription
Elements of a Complete Pediatric Prescription:
Full name
Date of birth
Current weight
Known allergies and reaction
Diagnosis
Medication name, dosage form, and strengths
metric units
for liquids, provide dose as well as volume (i.e., 10 mg/2 mL)
Dispensed amount
Calculations - mg/kg/day - to allow for 2nd check
Complete administration instructions
Prescriber's name and contact information
27
Elderly Prescribing Cascade
Pharmacist’s Letter: Reducing Medication Errors in High-Risk Situations and Populations
28
Avoiding Errors
The FDA has worked to review confusing drug names, improve packaging, require identification bar codes, and educate patients
Campaigns such as the “5 Rights of Medication Administration”
right drug, right patient, right dose, right route, right time
Medication reconciliation
Computerized systems
Interdisciplinary approach
Wittich CM, Burkle CM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc. 2014;89:1116–25
29
Examples
Wittich CM, Burkle CM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc. 2014;89:1116–25
33
Disclosure and Legal Consequences
Disclosure of medication errors:
for the benefit of an individual patient
to provide data for broader, systemic insights into any
recurring patterns of errors
Legal consequences:
can include civil actions, criminal charges, and board
discipline
35