SAFETY CONCERNS WITH MULTIPLE MEDICATIONS AND BEYOND Sandra Brownstein, PharmD, CGP Objectives: List potential medication related problems that increase in the frail elderly with acute illness Differentiate between medication related problem and true medication error and describe how to prevent them Discuss development of medication reconciliation programs between healthcare settings DISCLOSURE Sandra Brownstein, PharmD does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and or provider(s) of commercial services discussed in the presentation. Arizona Geriatrics Society. 42
Slide 1 Safety Concerns with multiple medications and beyond The need for medication reconciliation across care settings to avoid adverse drug events! Sandra Brownstein, PharmD, CGP Evercare Pharmacy Director DO NO HARM: Nursing Frail Elders Through Acute Illness Slide 2 Objectives 1. Differentiate between medication errors, Adverse Drug Events, and Medication Related Problems 2. List reasons for medication reconciliation across care settings 3. Describe barriers to medication reconciliations 4. Develop reconciliation program to reduce medication errors and adverse drug events when the patient is moving within care settings especially with acute illness. Slide 3 Statistics 1. 33% of elderly on >5 meds will experience at least 1 ADE / year 2. 2/3 of these ADE will require medical attention 3. 95% of reactions are predictable and 28% are preventable 4. There are 7000 deaths per year due to ADE(low number) 5. ADE accounts for at least 7% malpractice claims 6. Hospitalized patients with ADE are twice likely to die as compared to patients without ADE 7. 47% of medication errors occur at transition of care points. Arizona Geriatrics Society. 43
Slide 4 Definitions Medication Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Adverse drug event Any injuries attributable to the use of medications Slide 5 Definitions Medication Related Problem An event or situation involving drug therapy that actually or potentially interferes with an optimum outcome for a specific patient. Untreated conditions Drug use without indication Improper drug selection Subtherapeutic dosage Overdosage Adverse Drug Event Drug interactions Failure to receive medication Slide 6 A few more definitions Polypharmacy Inappropriate use of multiple drugs Polypharmacy increases risk of drug-drug interactions and adverse drug events Medication Includes prescription medications, over-thecounter medications and alternative or herbal remedies Arizona Geriatrics Society. 44
Slide 7 Last definition Medication Reconciliation The process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency and route and comparing that list against the physician s admission, transfer, and / or discharge orders, with the goal of providing correct medications to the patient at all transition points. Slide 8 Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population Slide 9 Any symptom in an elderly patient should be considered a drug side effect until proven otherwise Arizona Geriatrics Society. 45
Slide 10 Medication Errors Poor communication Misinterpreted handwriting Drug name confusion Employee lack of knowledge Misunderstanding of drug directions Multiple factors in a complex medical system Slide 11 Med Error Reduction Bar Coding Arm band bar coded Medications bar coded Electronic medication administration records Drug Name Confusion FDA program to identify similar names before drug released to market Drug Labeling Standardize OTC labels Slide 12 Methadone Lanoxin Serzone Lamictal Lamisil Ludiomil Zantac Zyrtec Celebrex Drug Name Confusion Methadate Levoxine Seroquel Lamisil Ludiomil Lomotil Zyrtec Zyprexa Celexa Arizona Geriatrics Society. 46
Slide 13 Med Error Reporting www.fda.gov/medwatch/how.htm www.ismp.org/pages/consumer.html www.usp.org Very important to report errors and side effects or medication related problems Slide 14 Adverse Drug Events Avoid overuse, misuse or underuse Very common but often overlooked More likely in elderly due to predisposition Can be controlled with medication reconciliation Slide 15 Avoid misuse of medications Potentially inappropriate medication Beer s Criteria Lowest effective dose Discontinue when no longer needed Determine risk / benefit to continue Arizona Geriatrics Society. 47
Slide 16 Avoid overuse of medications Polypharmacy Increase meds increase risk of drug drug Reduce polypharmacy with help of pharmacist and nursing Look at non pharmacological treatment Risk / Benefit evaluation Look at outcome potential ie palliative care Slide 17 Avoid underuse of medications Underprescribing Under diagnosed Undertreated Non adherence Physician/ patient communication Cognitive decline Cost of medication Slide 18 Medication Reconciliation Poor communication at transition points 50% med errors with 20% Adverse Drug Events. Goal is to create the most accurate list of all meds patient is currently taking including herbal nutraceuticals and OTC products. 3 step process Verification Clarification Reconciliation Arizona Geriatrics Society. 48
Slide 19 Verification Collection of the medication history Patient Previous care site / placement Caregiver / family More important of current medications not necessarily history History is important for treatment Slide 20 Clarification Ensure meds and doses appropriate Ensure meds are accurate Make sure all drugs included in list Time to provide medication therapy management and identify pharmaceutical care issues Slide 21 Reconciliation Documentation of all changes in the orders Physician review and approve all changes Update at all changes in care including drug changes and movement to different care setting Arizona Geriatrics Society. 49
Slide 22 Tips for implementation of Reconciliation program Patient is first in importance Patient should be engaged in process if possible Patient is the only constant in the reconciliation process Must have team approach Don t reinvent the wheel Reach beyond the institution Evaluate the current system Slide 23 Tips for collecting accurate med list Start with the best list List sources of information Streamline the collection process determine who can do it best Nurse / pharmacist / technician / physician Develop or adopt complete collection tool Interview all involved, patient / caregiver/ family Continue to engage patient throughout whole process if possible. Slide 24 Tips for reconciliation on Transfer Continue to reconcile form upon orders being rewritten Need to update reconciliation form when change in setting, service provider, level of care and any new orders This becomes a living document in continuous change Arizona Geriatrics Society. 50
Slide 25 Tips for reconciliation on discharge Print out most available pharmacy profile Review with patient or patient advocate to ensure correct Involve the pharmacist in discharge planning Be sure pharmacy can explain medications Slide 26 Tips for ambulatory procedures or ER Visits Differentiate the need for medical history or reconciliation (they are different) Continue to try to have snapshot of current regimen ( this should be what the patient is actually taking not necessarily what was prescribed. Empower patient to keep list up to date Slide 27 Tips for teamwork Engage and educate community Try to standardize process across different settings Involve patient is all aspects of process Work with pharmacies, clinics, specialist to keep standard and updated. Arizona Geriatrics Society. 51
Slide 28 Notes for patients Stress importance of keeping updated medication lists Be sure to list current regimen Name of medication Dosages of current therapy Time when medication is taken and if with food or not What dosage form is used ie liquid, tablets.. Slide 29 More for the patient Utilize pharmacist for medication therapy management. Use the same pharmacy as much as possible Realize problems with Part D and maintaining list of all medications consumed Slide 30 In conclusion Our population of frail elderly that find themselves in an acute situation are at highest risk for adverse drug event. Adverse drug events increase with polypharmacy and change in placement Medication errors can lead to adverse drug events Patient need to be in charge of their medications and history of problems Requires teamwork and cooperation from all disciplines of healthcare Medication reconciliation is an effective program to reduce the risk of adverse drug events and to prevent other medication related problems. Arizona Geriatrics Society. 52
Slide 31 Thank you Sandra Brownstein, PharmD, CGP Pharmacy Director Evercare Southwest 520-906-8978 sandrab33@aol.com Arizona Geriatrics Society. 53