Meeting Professional Standards of Practice MDSCarePlanBuilder.com Unnecessary Medication Use Debbie Ohl RN, NHA, M.Msc., Ph.D Ohl & Associates Consultant and Educator MDSCarePlanBuilder.com
What are Unnecessary Medications?
Without adequate monitoring
Without adequate indications for use
Presence of adverse consequences indicating dose should be reduced or discontinued.
In your own words, what do you consider to be unnecessary drugs?
UNNECESSARY MEDS ARE D 2 UM MDSCarePlanBuilder.com DOSE, DURATION, USE, & MONITORING ARE NOT IN PLACE
Unnecessary Drug Use
Drug Regimen Review
Professional standards of practice
There are 5 questions to consider to prevent connecting these F-tags to one another
Do the target symptoms warrant medications?
Are non-pharmacological interventions in place and relevant?
Is medication appropriate to manage the symptoms or condition?
Do the intended or actual benefits justify the risk of use?
Is there a system in place to insure these criteria are adhered to?
Key Terms Linked to Unnecessary Med Use
ADE : Adverse Drug Effect
ADR : Adverse Drug Reaction
Professional standards of practice
Defining Key Terms
ADVERSE DRUG EFFECT:
Basket term that captures med errors and ADR’s.
ADEs can have different outcomes: worsening of existing condition, or lack of expected improvement .
Statistically: 2 ADE’s /100 residents More than half of adverse drug events may be preventable.
ADVERSE DRUG REACTION:
Any unintended response to a drug that is Harmful / noxious in doses for diagnosis, prophylaxis, or therapy.
High risk med categories: Psycho tropics, analgesics, anticoagulants, antibiotics, cardiovascular
Key Terms cont’
Polypharmacy : lots of meds
Predicatblitiy: primary concern
Any preventable event that can cause or lead to inappropriate medication use or patient harm while the medication is in control of the health professional.
DAMP: mistakes are related to dispensing, administering, or monitoring , prescribing ,
5 errors / 100 residents
BEERS LIST: medication with high risk side effects that outweigh benefits of use; meds that are inappropriate at any dose; specific meds used at low with caution.
Immediate Jeopardy: scope
H I L K L
STANDARDS of PRACTICE:
The various practice regulations in each State, and commonly accepted health standards established by national organizations, boards and councils.
Failure to protect from undue adverse med consequences or failure to provide med as prescribed.
Administration of medication to an individual with a known history of allergic reaction to that medication.
Lack of monitoring and identification of potential serious drug interaction, side effects and adverse reactions.
Administration of contraindicated medications.
Pattern of repeated medication errors without intervention.
Lack of timely and appropriate monitoring required for drug titration .
MDSCarePlanBuilder.com From a citation perspective, what are the potential scope and severity of slide 10 failures and why? Degree of the Problem Isolated Pattern Wide-spread Immediate Jeopardy J K L Actual Harm G H I Potential for Harm D E F No harm likely A B C
Adverse Drug Events
Pharmacodynamics : drugs with similar or opposing effects
Pharmacokinetics : what the body does to a drug
Pharmacokinetics : ADME What the body does to a drug
ABSORPTION: bowel surface decreases with age and gastric juices increase.
DISTRIBUTION: Total body water decreases 10 to 15% with aging. Results in possible higher blood concentrations of some water-soluble drugs;
Body weight that is body fat increases from 18 to 36% in men and from 33 to 45% in women. Result is fat soluble drugs take longer to eliminate.
METABOLISM: liver mass and blood flow decrease = harder to breakdown and eliminate
ELIMINATION : renal mass and blood flow decrease = reduced elimination of drug.
Preventable Adverse Drug Effects
Occur at Ordering
Wrong drug choice
Failure to consider drug interactions
Occur at Monitoring
Failure to order specific monitoring needs
Delayed response or failure to respond to signs &
symptoms of toxicity or lab evidence of toxicity
An adverse drug reaction is any unexpected, unintended, undesired, or excessive response to a drug that requires
Discontinuing the drug (therapeutic or diagnostic)
Changing the drug therapy
Modifying the dose (except for minor dosage adjustments)
Necessitates admission to a hospital
Prolongs the stay in a health care facility
Necessitates supportive treatment
Significantly complicates diagnosis
Negatively affects prognosis
Results in temporary or permanent harm, disability, or death
NEW or rapid decline; decline in function or tolerance
Change in function or status
Mental and Psychosocial function
Change in behavior, depression, mood, agitation, restlessness, confusion, delirium
Physician Services and Visits
Procedures in place to resolve concerns
Medical Regimen Review
Predictability Reactions can be immediate as in anaphylaxis, but generally requires 5 days of treatment, most show by 12 weeks
Usually dose dependent.
Most identified prior to marketing.
Can be due to concomitment disease, drug/drug, and food/drug interactions.
Rarely life threatening but can produce significant disability.
Usually not an extension of the known drug properties.
Generally independent of dose and route of administration.
Includes idiosyncratic reactions, immunologic or allergic reactions.
Tend to concentrate in liver, kidneys, and nervous system.
Types of Adverse Drug Reactions
Drug / Drug Interactions
Drug / Nutrient Interactions
Allergic Reactions / Hypersensitivity
DRUG / DISEASE INTERACTIONS
Prevalence of ADR-related Hospitalizations ranges from 5% to 35%. ADEs are estimated to cost the health care system $75 billion to $85 billion annually.
Drug / Drug Interactions: PHARMACOKINETICS AND DYNAMICS 40% elderly at risk
Drug / Nutrient Interactions:
Allergic Reactions / Hypersensitivity
Drug Toxicity: concurrent use of different drugs with same toxicity side effects
DRUG / DISEASE INTERACTIONS: exacerbation of the disease by the drug (i.e. anti-cholinergic are the most common cause: glaucoma, BPH, ALTZ, dry eye)
Understand pharmacokinetic and pharmacodynamics.
Monitor drugs with narrow therapeutic range.
Know, convey, and document baseline status.
The pharmacist is the primary gatekeeper: Monthly or more often (worsening status first 30 days).
MRR (medication record review) is designed to:
Factors that Produce/ Contribute to Inappropriate Drug Use
Under use of medications
Over use of medications
Excessive dose or duration
Lack of assessment
Lack of monitoring
Lack of recognition of ADR’s
Lack of adherence to drug therapy
Assessing a Possible ADR
Review the current medications in use for associations with symptoms or condition change.
Assess other possible causes for signs and symptoms.
Validate the drug ordered is the drug given.
Verify that the onset of the event was AFTER
drug administration initiated.
5. Determine the time interval between the beginning of drug treatment and the onset of the event.
Safeguards Prevention of Adverse Drug Reactions
Consider any new symptom as a possible ADE before requesting/ administering new medication for the symptom.
Monitor medication orders for wrong drug choices (high-risk inappropriate medications, drug–disease and drug–drug interactions), wrong dosages, or admin errors.
Improve prescribing practices by documenting:
+ indication for initiation of new drug therapy
+ maintaining a current medication list
+ documenting response to therapy.
Concomitant use of multiple drugs, done by simply drug counting.
Administration of more medications than is
34% of all drugs prescribed in the United States are considered unnecessary.
MDSCarePlanBuilder.com References: Stewarb RB. Polypharmacy in elderly: a fair accompli? DICP 1990; 24; 321-323. Montamat SC, Cusack B. Overcome the problems with polypharmacy and drug misuse. Clin Geriatr Med 1992; 8: 143-158. LeSage J. Polypharmacy in the geriatric patient. Nurs Clin North Am 1991; 26: 273-287 .
Possible Impacts of Polypharmacy
Adverse drug reactions
Medication errors made up of non-compliance
Link to 5% of hospital admission
Preventing Polypharmacy Gather information
Determine all medications being used.
Identify meds by generic name & drug class.
Identify the clinical indication of each medication.
Know the side effect profile of each medication.
Identify risk factors for an adverse drug reaction.
MDSCarePlanBuilder.com Resident Medication Profile Medications (brand and generic) Drug Class Clinical indication Common Side Effects Expected Response
Preventing Polypharmacy Eliminate, Substitute and Simplify
Eliminate medication with no therapeutic benefit.
Eliminate medication with no clinical indication.
Substitute a safer medication.
Avoid treating an adverse drug reaction with a drug.
Use a single drug with an infrequent dosing schedule.
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health professional.
Pharmaceutical Process Where Drug Errors are Most Likely to Occur
MDSCarePlanBuilder.com Process Causative Problems & Reasons For Potential Solutions Prescribing Transcribing Dispensing Administering