polypharmacy and medication errors

POLYPHARMACY AND

MEDICATION ERRORS

Leonardo Rosario-Colón, Pharm.D., R.Ph., B.S.

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.

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POLYPHARMACY

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.

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Polypharmacy Risk Factors

Elderly

Multiple comorbid conditions

Recent hospitalization

Multiple physicians

Multiple pharmacies

Inappropriate medication

Poor documentation

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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

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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

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Negative Outcomes

Polypharmacy has been shown to increase:

Unnecessary / inappropriate medication prescribing

Risk of drug interactions / adverse drug reactions

Medication nonadherence

Overall drug expenditures

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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

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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

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“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.

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“Deprescribing” Algorithm

Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175:827-34.

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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

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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)

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START/STOPP

Pharmacist’s Letter: Reducing Medication Errors in High-Risk Situations and Populations

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MEDICATION ERRORS

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.

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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

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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.

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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.

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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.

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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.

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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/

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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.

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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

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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

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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

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Elderly Prescribing Cascade

Pharmacist’s Letter: Reducing Medication Errors in High-Risk Situations and Populations

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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


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Be Careful…

Institute for Safe Medication Practices. http://www.ismp.org/

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Avoid Error-Prone Abbreviations


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Avoid…


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Examples


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Examples 34

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

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QUESTIONS?

POLYPHARMACY AND

MEDICATION ERRORS

Leonardo Rosario-Colón, Pharm.D., R.Ph.

polypharmacy and medication errors

Health & Medicine