Risk Management Meeting Todays Challenges Medication Management

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Risk Management Meeting Todays
ChallengesMedication Management

• Dave Cosh
• Pharmacist

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Issues

• Error free dispensing
• Error free administration
• Storage when it matters
• Paying attention to timing for those drugs that
  matter
• Being alert for benefits
• Being alert for adverse effects

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Nurses and carers are with residents on a
constant basis day after day On many occasions GP
visit is precipitated by concerns expressed by
the above It therefore makes good sense for both
nurses and carers to have an appreciation of
possible adverse effects of commonly used
medications that can be picked up by observation
(some cannot) Common things happen commonly and
this is where the emphasis should be
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Mrs GD

• A 67 yo lady is residential care with a medical
  history of Congestive cardiac failure Atrial
  fibrillation Hypertension Osteoarthritis Insomnia
• Lanoxin PG 3 morning
• Lasix 80mg morning
• Renitec 10mg morning
• Panadol 500mg One to Two four times a day prn
• Temaze 10mg night
• Her GP has recently started Celebrex 100mg twice
  a day for her arthritis

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Since starting Celebrex

• Regular nursing staff have noticed an increasing
  disinterest in food and the occasional complaints
  of nausea. Mrs GD is not her usual self and
  this has been noticed by her family when they
  visit these are very important observations
• ? Are any of the drugs she is taking a likely
  culprit

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Hospitalised patients Incidence of GI unwanted
affects with Lanoxin (Digoxin)
TR
FMC Data Dr Sepehr Shakib
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Factors that can impact on kidney Dehydration
Lasix increases the risk Reduced perfusion
pressure Renitec does this Reduced blood flow to
the kidney Celebrex and all NSAIDs can do
this Referred to as a Triple Whammy
Excretion reduced
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Mr SP

• 77 year old man with a history of STML,
  Depression and crush fractures secondary to
  osteoporosis.
• Aropax 20mg morning
• Fosamax 70mg once a week on a Saturday
• Serepax 30mg night
• Neither Panadol nor Capadex have effectively
  controlled his pain and his GP started him on
  Tramal 100mg twice a day

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Mr SP

• Nursing staff noted that within 48 hours of
  starting Tramal he became agitated, more
  confused, and developed a fever. The GP asked
  that the Tramal be ceased and he settled over 24
  hours back to his normal state. He was started on
  a small dose of MS Contin and his pain settled
  Nursing staff started Coloxyl with Senna and
  Actilax at the same time (nurse initiated)

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Two examples of where a combination of drugs has
caused the problemnot a criticism of prescribing

• Tramal added in to a drug that already increases
  central levels of serotonin pushes up levels of
  serotonin further with well-described outcomes

• Digoxin toxicity secondary to Celebrex acting as
  the last straw on kidneys already stressed by
  CCF, Lasix and Renitec

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How to minimise risk?Easy to say harder to
do!!!

• Education good texts (latest editions and
  online) and IT support and training.
• More staff in residential care!!
• More GPs more geriatricians
• A better model for pharmacist medication review
• Put the acid on your pharmacists to provide
  education

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Serotonin SyndromeAust Prescr 20032662-3)

• 3 very simple steps
• Google and entered ltAustralian Medicines
  Handbookgt
• Clicked on link to ltAustralian Prescribergt and
  entered ltserotonin syndromegt in the search box.
• Found full text version of above article with a
  comment for consumers

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Serotonin syndrome Medicines for depression alter
the balance of chemicals in the brain. Some
antidepressant medications increase a chemical
called serotonin, however too much serotonin can
cause side effects. The side effects of serotonin
are more likely if the patient is taking two
medicines which increase serotonin. These
medicines include some painkillers Tramal is
oneand some herbal medicines, like St John's
wort, as well as antidepressants. Too much
serotonin causes confusion, sweating,
unsteadiness, shaking and diarrhoea. These
symptoms usually get better if the patient stops
taking the medicines. More severe cases may
require treatment in hospital and a few may be
fatal
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Summary Increasing educational supports for the
public principally via the Net and support
groups Industry pushing for direct to consumer
advertising a double edged sword! Educational
supports for professionals in the public health
sector are good ? In the private sector the
level of risk associated with drug use can be
reduced by investing in education for those
charged with the responsibility of administering
these drugs