Medication Safety

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Medication Safety

• Christopher Roy
• Annie Helgason
• BWF Hospitalist Service
• April 6, 2005

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Case from the Faulkner

• CC altered mental status
• HPI 82 yo F CAD, Htn, DM, meningioma,
  hypothyroidism, and mild dementia, admitted to FH
  with lethargy, hypoxia, and garbled speech.
• d/cd 3 days PTA after hospitalization for
  SBO/ileocecal mass (adenoCA)
• PMH as above, also renal cell carcinoma, s/p L
  nephrectomy 1998, CRI (1.4-1.8)

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Medications on Transfer

• toprol xl 50 mg qd
• famotidine 20 mg qd
• valproic acid 250 mg tid
• amlodipine 5 mg qd
• atorvastatin 40 mg qd

• donezapil 5 mg qd
• desipramine 150 mg bid
• levothyroxine 100 mcg qd
• valsartan 80 mg qd
• colace 100 mg bid
• senna 1 tab qd

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Continued..

• Allergies PCN, ACEI
• SH independent, lives with husband
• No tob/etoh/illicits

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Physical Exam

• T 96.4 P 75 BP 166/82 RR 18 92 RA
• elderly woman, NAD, somnolent but arousable with
  somewhat slurred speech.
• OP dry and crackles heard at the R lung base.
• AXO x 2. MAE and follows simple commands, but
  unable name days of week.

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Data

• EKG SR with 1st degree AVB, LAHB, RBBB.
  Compared with prior, PR and QRS slightly longer.
• Labs, U/A unremarkable.
• CXR small infiltrate at R base.
• Head CT stable meningioma L frontal lobe

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Treatment

• Given antibiotics, supplemental O2
• MRI done?stable meningioma
• Mental status cleared very slowly

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Review of LMR

• Review of PCP notes
• pt on disopyramide 150mg bid
• class 1a antiarrhythmic
• desipramine 150mg bid listed in MAR

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Case, continued

• Desipramine
• Tricyclic antidepressant
• Usual adult dose is 100-200 mg per day
• Maximum dose in geriatric pts 100 mg per day

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Desipramine side effects

• Cardiovascular Arrhythmias, hyper-/hypotension,
  palpitation, heart block, tachycardia
• Central nervous system Dizziness, drowsiness,
  headache, confusion, delirium, hallucinations,
  nervousness, restlessness, parkinsonian syndrome,
  insomnia, disorientation, anxiety, agitation,
  hypomania, exacerbation of psychosis,
  incoordination, seizure, extrapyramidal symptoms
• Neuromuscular skeletal Fine muscle tremor,
  weakness, numbness, tingling, paresthesia of
  extremities, ataxia

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Case continued

• Desipramine level 43 ug/L
• (therapeutic range 150-300 ug/L)

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Definitions

• Medication error any error in ordering,
  transcribing, dispensing a medication (whether
  harm occurs or not)
• Preventable adverse drug event (ADE) medication
  error that results in harm
• Non-preventable ADE unanticipated untoward
  effect of medication (e.g. pcn allergy in pt who
  has never received pcn)
• Potential ADE medication error? near-miss,
  either intercepted or by luck
• Medication-related problem (whole universe of
  treatment failures, adverse drug events)

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Non-preventable
Medication Errors
ADEs
Potential ADEs
Preventable
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Cost of Medication Related Problems (includes
treatment failures, adverse drug events)

• 115 million excess physician visits
• 17 million emergency department visits
• 8 million hospital admissions
• 3 million long-term care admissions
• 200,000 deaths
• 76 billion in total costs annually

Johnson JA 1995
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Inpatient Costs of ADEs

• Most common inpatient adverse event
• 2400 per ADE
• 4500 per preventable ADE

Bates et al. JAMA 1997
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Malpractice Implications

• 12 of all Professional Liability claims are
  medication related (56 outpatient)
• The most commonly named specialties
• General Medicine
• Psychiatry
• OB/GYN
• 51 of the defendants named are physicians
• 70 Staff
• 25 Residents
• 5 Fellow
• 13 of the defendants are nurses

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Outpatient ADEs

• Study of 1202 outpatients who received at least 1
  prescription med
• Among 661 who responded to survey
• 162 (25) had at least one ADE
• 27 events per 100 patients
• 13 serious, 28 ameliorable, 11 preventable
• Among 51 ameliorable ADEs
• 63 attributed to MD failure to respond to
  symptoms
• 37 attributed to patient failure to report
  symptoms
• Most frequent medications
• SSRIs, Beta-blockers, ACE I, NSAIDs
• Only number of medications associated with rate
  of ADEs
• Gandhi et al. NEJM 2003

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Admissions Due to ADEs

• Few recent data
• Wide range 0.5-21 of all admissions
• One recent study at BWH found 1.4 of admissions
  were due to ADEs
• Originate in outpatient setting
• 78 severe
• 28 preventable
• Bates, et al. Unpublished data

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Inpatient ADEs

• 5-40 of patients have ADE while in hospital
• Approximately 50 judged to be preventable
• 12-17 have ADE within 1 month of discharge
• 24 preventable
• 38 ameliorable

Steele 1981, Carbonin 1991, Bates 1995, Forster
2003
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ADEs After Discharge

• 12-17 of patients within 30 days of discharge
• 24 preventable
• 38 ameliorable
• 11 went to Emergency Dept., 24 readmitted
• Most common drugs
• Antibiotics, corticosteroids, cardiovascular,
  analgesics, anticoagulants
• System problems
• Poor communication with patient or PCP
• Inadequate patient education
• Insufficient monitoring after discharge
• Forster 2003, 2004

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Causes of the Problem

• Problems throughout the lifecycle of
  prescription medications
• 1. Inappropriate prescribing
• 2. Errors of dispensing and administration
• 3. Medication Discrepancies
• 4. Non-adherence
• 5. Inadequate surveillance and monitoring

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Inappropriate prescribing

• Polypharmacy
• -Medications without clear indication (59 of
  ambulatory elders)
• -How many meds is too many?
• Inappropriate use (82 elderly inpatients)
• -Improper drug selection, drug-disease,
  drug-drug interactions
• -Beers list of inappropriate meds in the
  elderly
• -ACOVE measures (avoid demerol, anticholin)
• Under-prescribing appropriate meds

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Errors of dispensing and administration

• Illegible prescriptions are 15 of the errors
  reported to USP
• Look-alike/Sound-alike names
• Abbreviations
• Errors in ordering dose
• Errors in route
• Abbreviations in directions

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Look Sound-Alike Drugs

• Mellaril Elavil
• Paxil Taxol
• Prilosec Prozac
• Cerebyx Celebrex
• Oxycontin Oxycodone
• Hydroxyzine Hydralazine
• Alprostadil Alprazolam

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Medication Discrepancies

• Error of communication, information systems
• Newly appreciated problem
• At admission, 49-54 of patients
• Immediately after discharge, 29 of patients
• One month after discharge, 50-90 of patients

Gleason 2004, Cornish 2005, Schnipper 2003
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Medication Discrepancies

• Worsens with every transition of care
• 40 of old meds are discontinued by discharge
• 45 of discharge meds are new to patient
• Average elderly pt gets 5.3 minutes of education
  about meds (50 receive none)

Beers 1989, Alibhai 1999
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Non-adherence

• Typically estimated to be 50
• Recent survey of outpatients, with last 12 months
• -30 took meds less often than prescribed
• -26 delayed filling prescription
• -21 stopped taking prescription sooner than
  prescribed
• -18 never filled a prescription
• -14 took smaller doses than prescribed
• Data using electronic pill caps are even worse

Sackett 1979
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Inadequate surveillance

• Drug levels
• Disease control
• Development of side effects
• Problems with access to health care,
  discontinuity in care, patient knowledge

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So what can we do??
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What to do

• Review med lists daily, looking for polypharmacy,
  interactions, inappropriate or unnecessary meds
• CPOE, e-scripts, EMAR/barcoding
• Med reconciliation at every transition (JCAHO
  mandate by 2006)
• Pt education, pharmacist involvement, pillboxes,
  adherence clinic, access issues
• VNA, coumadin clinics, disease management, early
  follow-up, post-discharge clinic or telephone
  call

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Case, redux

• Was this an example of
• a) preventable ADE
• b) potential ADE
• c) medication error
• d) medication related problem
• e) just another day at the Faulkner?
• Could this have been prevented? How?