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Polypharmacy and medication errors
This document discusses polypharmacy and medication errors. It begins by defining polypharmacy as the use of multiple medications where more are being used than clinically indicated. Polypharmacy can increase the risk of drug interactions and adverse events. Common risk factors for polypharmacy include the elderly, multiple comorbidities, recent hospitalization, and multiple physicians or pharmacies. Medication errors are also defined as any error in the medication use process and examples are provided. Reporting systems for medication errors and the most commonly implicated drug classes and individual drugs are outlined. Risk factors for errors and recommendations to reduce polypharmacy and errors are presented.
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Polypharmacy and medication errors
- 1. POLYPHARMACY AND MEDICATION ERRORS LeonardoRosario-Colón, Pharm.D., R.Ph., B.S.
- 2. Objectives Goals andObjectives: 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. 2
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- 4. 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. 4
- 5. Polypharmacy Risk Factors Elderly Multiple comorbid conditions Recent hospitalization Multiple physicians Multiple pharmacies Inappropriate medication Poor documentation 5
- 6. 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 6
- 7. Patient’s Factors Multipleproviders 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 7
- 8. Negative Outcomes Polypharmacyhas been shown to increase: Unnecessary / inappropriate medication prescribing Risk of drug interactions / adverse drug reactions Medication nonadherence Overall drug expenditures 8
- 9. Example 85 y/owoman 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 9
- 10. 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 10
- 11. “Deprescribing” Process oftapering 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. 11
- 12. “Deprescribing” Algorithm Scott IA,Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175:827-34. 12
- 13. High Risk Medications SideEffect 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 13
- 14. Recommendations Use toolsto 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) 14
- 15. START/STOPP Pharmacist’s Letter: ReducingMedication Errors in High-Risk Situations and Populations 15
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- 17. 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. 17
- 18. Examples Medication errorscan 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 18
- 19. 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. 19
- 20. ASHP Categories AmericanSociety 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. 20
- 21. Other Categories TheNational 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. 21
- 22. Incidence Medication errorsare 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. 22
- 23. Reporting Voluntary reportingsystems 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/ 23
- 24. Top Drugs Top10 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. 24
- 25. Risk Factors Unapprovedabbreviations 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 25
- 26. Pediatric Medication Errors InpatientOutpatient 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 26
- 27. Pediatric Prescription Elementsof 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 27
- 28. Elderly Prescribing Cascade Pharmacist’sLetter: Reducing Medication Errors in High-Risk Situations and Populations 28
- 29. Avoiding Errors TheFDA 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 Wittich CM, Burkle CM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc. 2014;89:1116–25 29
- 30. Be Careful… Institute forSafe Medication Practices. http://www.ismp.org/ 30
- 31. Avoid Error-Prone Abbreviations Institutefor Safe Medication Practices. http://www.ismp.org/ 31
- 32. Avoid… Institute for SafeMedication Practices. http://www.ismp.org/ 32
- 33. Examples Wittich CM, BurkleCM, Lanier WL. Medication errors: An overview for clinicians. Mayo Clin Proc. 2014;89:1116–25 33
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- 35. Disclosure and LegalConsequences 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 35
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- 37. POLYPHARMACY AND MEDICATION ERRORS LeonardoRosario-Colón, Pharm.D., R.Ph.