Objective. A Multi Incident Analysis on Potentially Inappropriate Medication Use in Older Adults. Outline

Transcription

1 A Multi Incident Analysis on Potentially Inappropriate Medication Use in Older Adults Kelly Ng BSc (Hons), PharmD Candidate Analyst, ISMP Canada 2015 Institute for Safe Medication Practices Canada. This video is for educational purposes only. Reproduction by any other processes is prohibited without permission from ISMP Canada in writing. Objective Understand the vulnerabilities associated with older adults Identify potential contributing factors and recommendations to help prevent medication errors in this population Outline Overview of ISMP Canada and the Community Pharmacy Incident Reporting (CPhIR) Program Introduction: The Problem with Older Adults Multi Incident Analysis Methodology Results and Recommendations Conclusions 1

2 About the Institute for Safe Medication Practices Canada (ISMP Canada) ISMP Canada is an independent not for profit organization dedicated to reducing preventable harm from medications Our aim is to heighten awareness of system vulnerabilities and facilitate system improvements canada.org Community Pharmacy Incident Reporting (CPhIR) Program An online incident reporting and analysis platform for community pharmacies Contributes to the Canadian Medication Incident Reporting and Prevention System (CMIRPS) Facilitates learning from medication incidents in a systematic manner Promotes development of system based strategies for quality improvement and error prevention 2

3 The Problem with Older Adults Older adults are the greatest consumers of medications, yet they are underrepresented and excluded in many drug trials So what? Optimizing treatment is difficult Evidence supporting guideline driven therapeutics cannot be generalized to older adults Older patients with comorbid conditions are often excluded from clinical trials and clinical guidelines 1 3 Adhering to current clinical practice guidelines for an older person with several comorbidities may have undesirable effects with a substantially increased risk of over dosing, under dosing, adverse drug events, drugdrug or drug disease interactions 1 4 In 2012, 24% of older adults on a public drug program receive at least one prescription considered inappropriate for this age group 3 Almost half of older adults taking five or more medications experienced preventable side effect requiring medical attention 1 3

4 Where does this lead us? Lists and criteria to prevent potentially inappropriate prescribing Beer s list 5 STOPP criteria 6 Anticholinergic burden scale 7 Multi incident analysis: Explore the current state of inappropriate prescribing by identifying medication incidents related to inappropriate medication use Identify points of intervention in the community setting to prevent potentially inappropriate medication use that may compromise patient safety Methodology Searched Community Pharmacy Incident Reporting (CPhIR) Database Incidents involving Therapy Problems, Contraindications, and Duplications in Patients > 65 years old Selected 184 incidents for final analysis Identified themes and potential contributing factors Provided recommendations to fill in patient safety gaps Limitations Bias due to voluntary nature of reporting system Lack of incident details 4

5 Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications Theme 1: Patient Specific Factors Medication was not best suited for the patient based on their specific needs Subthemes: Intolerance or allergies Medical conditions Inappropriate dosing or prescription Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 5

6 Theme: Patient Specific Factors Intolerance or Allergies Sample Case: The patient had previously been taking Accupril TM 20mg, and was getting a new prescription for Accuretic 20mg/12.5mg. When entering the prescription into the computer, the pharmacy assistant just copied the Accupril TM over to Accuretic instead of inactivating it and creating a whole new prescription from scratch. The patient had a documented sulfa allergy. When picking the prescription up it was noted that it was now a combo drug, but he said "oh yeah, I know all about it" so the pharmacist was not called over to speak to him about the addition, along with his allergy. He ended up having a slight adverse reaction, and slight lip swelling. We sent him to the doctor, and will now discontinue taking the Accuretic Accuretic Hydrochlorothiazide Sulfonamide Group Allergic Reaction with potential crossreactivities with sulfonamides 8 Therapeutic Category Antibiotics for Inflammatory Bowel Disease Anti inflammatory Hypoglycemic Agents Diuretics Migraine Therapy (Examples) Trimethoprim sulfamethoxazole Sulfasalazine Celecoxib Glyburide Gliclazide Furosemide Hydrochlorothiazide Sumatriptan Note: This is note a comprehensive list 6

7 Subtheme: Intolerance or Allergies Contributing Factors and Recommendations Lack of knowledge with sulfonamide cross reactivity Educate staff/physicians on medication classes with sulfonamide cross reactivity s Lack of transparency between Pharmacist and Physician for documented intolerances/allergies Share documented allergies and intolerances with prescribers 9,10 Assuming the patient knows all about it Engage in dialogue with the patient and/or the caregiver as a way to detect potential errors 11 Look alike, Sound alike drug names at order entry Implement computer mnemonics to minimize selection of the wrong medication 11,12 Independent double checks 11,13 Avoid copying prescriptions (Accessed: March 27, 2015) Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 7

8 Theme: Patient Specific Factors Medical Conditions Sample Case: Doctor wrote a prescription to the patient for Zostavax and she had a major contraindication to it (lymphoma) it was all discovered at the last moment just before she was injected Theme: Patient Specific Factors Medical Conditions Sample Case (Renal Failure): Pharmacist checking the [prescription] knew that her CrCl was very low and that this medication was contraindicated with CrCl<30ml/min Sample Case (Heart Conditions): The doctor didn't realize that the [patient has atrial fibrillation] and prescribed Avelox 400mg. This is contraindicated so the pharmacist sent off a fax to the doctor, and the doctor agreed that it should not be filled and switched it to doxycycline instead. Subtheme: Medical Conditions Contributing Factors and Recommendations Lack of knowledge to drug disease interactions Program the clinical decision support system (CDSS) to make the medical condition field mandatory Update drug disease interaction Establish a formal review process to assess and clarify any unfamiliar drug, new drug, or off labelled use drugs 12,13 Outdated records Make sure you are aware of your patient s current medical conditions and keep your records up to date (i.e. comprehensive medication reviews) 9, 10, 12 8

9 Comprehensive Medication Reviews A study by Hanna 15 demonstrated that MedsCheck was a good starting point for a cardiovascular risk reduction intervention Dolovich et al., 16 found that the MedsCheck service improved communication with other health care providers, and obtained a more accurate and complete patient profile. Primary barriers include the lack of time and a lack of pharmacist overlap coverage. 16 Practical Recommendations to Assist the Implementation and Delivery of Comprehensive Medication Reviews 9,10,12,16,17 Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 9

10 Theme: Patient Specific Factors Inappropriate dosing or prescription Sample Case: The Doctor prescribed fentanyl to an opioid naïve patient. The patient was taking only acetaminophen 650mg extended release. Administering fentanyl to this patient may have serious effects. Subtheme: Inappropriate dosing or prescription Contributing Factors and Recommendations Lack of knowledge or awareness of indications and pharmacokinetics (i.e. how the drug is affected by the body) 18 Program the CDSS to alert certain dosages for geriatrics, especially high alert medications and other medications affected by age related physiologic changes (i.e. metabolism, excretion) 18,19 Verify with the patient or caregiver any clinical information about the patient that is necessary to confirm the appropriateness of the medication and dose (e.g. opioid tolerance, indication for drug) 13,19 Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 10

11 Theme #2: Medication incidents involving two drugs that conflicted with one another, leading to toxicities or sub therapeutic effects. Subthemes: Antibiotics + Chronic between Chronic Duplications Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications Theme: Antibiotics + Chronic Sample Case: Significant interaction between [sulfamethoxazole/trimethoprim] and Warfarin was not caught until [patient] was being counseled and he asked if it interacted with his Warfarin. [Prescription] went through without flashing as a [drug interaction] and interaction note at bottom of [prescription] was not seen during checking. Important to always check interactions listed on hardcopy as they do not always flash as a [drug interaction] (not sure how threshold is determined in [the dispensing system]) 11

12 Subtheme: Antibiotics + Chronic Contributing Factors and Recommendations Faulty computer system that does not pick up on the drugdrug interaction 19 Ensure CDSS is maintained and updated regularly 19 Alert fatigue Review severity levels for drug drug interaction alerts in CDSS to balance information needs 13,19 Encourage the reporting of clinically insignificant warnings 13 Lack of independent double checks Perform independent double checks 11,14 Lack of full patient profile during prescribing Provide an up to date Comprehensive Medication Review document for the patient to carry and share information with providers within the patient s circle of care (i.e. My MedRec App) 10 Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 12

13 Theme: between Chronic Sample Case: Nurse from the nursing home called to inform us of a medication incident. Patient is on Eliquis and ASA 81mg and was prescribed naproxen for 2 weeks. Interaction between all may cause increase risk of bleeding. Patient had a nose bleed that wouldn t stop and ended up in hospital for treatment. Interaction wasn't relayed to doctor or staff of nursing home to monitor. Patient still in hospital so unknown what meds will be changed or discontinued Subtheme: between Chronic Contributing Factors and Recommendations Multiple medication use Comprehensive Medication Reviews and providing documentation for the patient and prescriber 9,10 Educate patients on the importance of retaining a medication list Lack of monitoring and follow up Have a systematic process to arrange for better patient care (e.g. schedule follow up reminders at time of dispensing) 17,20 Alert fatigue Review severity levels for drug interaction alerts 13,19 Main Themes Inappropriate Medication Use in the Geriatric Population Patient Specific Factors Intolerance or Allergies Antibiotics + Chronic Medical Conditions Between Chronic Inappropriate Dosing Duplications 13

14 Theme: Duplication Sample Case: Nursing home patient was on Osto D2 50,000 once daily since 2001 when he entered the home. The home recently started a Vitamin D/Calcium program so Vitamin D 1000 IU was added daily as well he was taking a multivitamin with Vitamin D. He developed Vitamin D toxicity. All vitamin D and Calcium was discontinued and adequate hydration was recommended. Physician, pharmacist and nursing staff all missed the multiple sources of vitamin D. Subtheme: Duplication Contributing Factors and Recommendations Lack of communication between healthcare professionals Implement policy and procedure to share Comprehensive Medication Reviews between practitioners 10,16 Lack of communication between healthcare professional and the patient Inquire about non prescription medications Clarify the indication of the drug with the patient (and prescriber) if necessary 19 Lack of knowledge of generic and brand names Ensure that all medication information available to patients and practitioners includes the generic name (e.g. medication labels, drug information documents, medication profiles) 11 Implement computer alerts to flag medications within the same class 18 Conclusions Summary of Analysis With age, people develop more chronic conditions, often resulting in more medications prescribed. Physiological changes associated with aging can increase the risk of medication errors. 2 common themes from a multi incident analysis of 184 medication incidents voluntarily reported to ISMP Canada s CPhIR Program: Patient specific factors interactions 14

15 Conclusions Potential System Based Safeguards Obtain a comprehensive medication history and keep this updated on a regular basis Share information with other healthcare professionals and the patient Pharmacy computer systems: Ensure the computer system is maintained regularly and is kept updated Review severity levels for drug drug interactions alerts in clinical decision support systems Avoid copying prescriptions Alert certain dosage schedules for geriatrics, if possible Schedule follow up reminders at time of dispensing to arrange for better patient care Incorporate pharmacy technicians and assistants into the workflow as much as possible to perform independent double checks Counselling patients: Inquire about non prescription medications Engage in dialogue with the patient and/or caregiver to detect potential errors Conclusions The general public expects comprehensive and complete care Healthcare professionals must meet these expectations by providing patient focused care 15

16 ISMP Canada is a key partner in the Canadian Medication Incident Reporting and Prevention System (CMIRPS) (416) or (866) Yonge Street Suite 501 Toronto, Ontario Canada M2N 6K8 info@ismp canada.org canada.org References 1. Kwan D. Polypharmacy: optimizing medication use in elderly patients. CGS Journal of CME. 2014; 4(1): Available from: D5B7 B425 A21527A9E6498A4D/showMeta/0/ 2. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294(6): doi: /jama Canadian Institute for Health Information. use among seniors on public drug programs in Canada, 2012 [Internet]. Ottawa, ON: 2014 [cited 2015 Mar 31].71p. Available from: Programs_2012_EN_web.pdf 4. related problems in the elderly [Internet]. New Jersey (USA): Merck Sharp & Dohme Corporation; 2014 [cited 2015 Mar 31]. Available from: 5. Campanelli CM. American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults: the American geriatrics society 2012 beers criteria update expert panel. Am Geriatr Soc April; 60(4): Available from: 6. Gallagher P, O Mahoney D. STOPP (Screening tool of older persons potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers criteria. Age and Ageing 2008; 37: Available from: 7. Anon. ABC Anticholinergic Burden Scale. Helping physicians do no harm. Available from: anticholinergic cognitive burden scale 8. Dibbern Jr DA, Montanaro A. Allergies to sulfonamide antibiotics and sulfur containing drugs. ANN Allergy Asthma Immunol. 2008;100: Yoo L, Ho C. Enhancing Medscheck, improving outcomes. Pharmacy Connection. [Internet] Mar. [cited 2015 Mar 31]. Available from: canada.org/download/pharmacyconnection/pc_marapr2010p7.pdf 10. Ontario Ministry of Health and Long Term Care. The MedsCheck program guidebook [Internet]. ON: Queen s Printer for Ontario; 2008 [updated 2011 Sept 13; cited 2015 Mar 30]. Available from: References 11. ISMP Canada. Concerned reporting: mix ups between bisoprolol and bisacodyl. ISMP Can Saf Bull [Internet] Aug 30 [cited 2015 Apr 3];12(9):1 6. Available at: canada.org/download/safetybulletins/2012/ismpcsb ConcernedReporting BisoprololandBisacodylMixups.pdf 12. ISMP Canada. Medication safety self assessment for community/ambulatory pharmacy. Canadian Edition. Toronto: ISMP Canada; ISMP. High alert medication modeling and error reduction scorecards [Internet]. Horsam: ISMP; 2012 [cited 2015 Apr 23] Available from: C Data Entry Errors DRUG.pdf 14. ISMP Canada. Lowering the risk of medication errors: Independent double checks. ISMP Can Saf Bull [Internet] Jan [cited 2015 Mar 30];5(1):1 2. Available from: canada.org/download/safetybulletins/ismpcsb pdf 15. Hanna J. Real world application of MedsCheck opportunities: the Costco pharmacists intervention trial for reduction of cardiovascular risk. CPJ/RPC [Internet] [cited 2015 Mar 30];146(6): doi: / Dolovich L, Gagnon A, McAiney CA, Sparrow L, Burns S. Initial pharmacist experience with the Ontario based MedsCheck program. CPJ/RPC [Internet] Nov [cited 2015 Mar 30];141(6): doi: / X Medscope. MedsCheck management system [Internet] [cited 2015 Apr 8]. Available from: ISMP Canada. Transdermal fentanyl: a misunderstood dosage form. ISMP Can Saf Bull [Internet] Aug 14 [cited 2015 Apr 3];6(5):1 3. Available at: canada.org/download/safetybulletins/ismpcsb Fentanyl.pdf 19. ISMP Canada. Preventable death highlights the need for improved management of known drug interactions. ISMP Can Saf Bull [Internet] May [cited 2015 Mar 31];14(5):1 7. Available from: 5_Known.pdf 20. National Association of Pharmacy Regulatory Affairs. Pharmacy care plans [Internet]. Ottawa (ON): National Association of Pharmacy Regulatory Affairs; 2006 [cited 2015 April 3]. Available from: 16