Transcript Slide 1

Medication-Related Problems
in the Nursing Home Setting
Steven M. Handler, MD, MS, CMD
Department of Medicine,
Division of Geriatric Medicine
and Department of Biomedical Informatics
Objectives
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Describe the medication use process in the nursing
home setting
Provide a conceptual framework for medication-related
problems
Discuss the epidemiology and impact of medicationrelated problems
Present current and future solutions for medicationrelated problems
To Err is Human: Building a Safer
Healthcare System
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This report focused national attention on the quality of
care and prevalence of medical errors in the healthcare
system
Largest proportion of medical errors are medicationrelated
Overwhelming majority of patient-safety initiatives
introduced to address concerns raised in this report have
been geared toward acute-care
Kohn, National Academy Press.
2000
Medications: A Love-Hate Relationship
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Geriatricians and their patients rely heavily on
pharmacotherapy to palliate symptoms, improve
functional status and quality of life, cure or manage
disease, and prolong survival
Medications are the most frequently used and misused
form of therapy
The benefits of medication therapy in older adults are
counterbalanced by the problems that they pose
Prescribing
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Complex medical patients
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Polypharmacy is the rule
rather than the exception
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Lack of evidence-base for
prescribing most
medications
Frequent lack of facilityspecific medication
formularies/Part D issues
Documenting/Order Communication
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Use of paper records and faxing of medication requests
to pharmacies is the rule rather then the exception
Frequent use of verbal (oral) orders
Process that often requires the nurse to act as an
“agent” of the prescriber
Dispensing
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Often no on-site pharmacy
Cycle/batch filling of
medications monthly in
blister packs
Often several different
pharmacies deliver
medications to patients
Pharmacy delivery schedule
is often once a day and an
e-box is available for
emergent medication needs
Administering
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Medication pass is one of
many tasks that nursing
staff are asked to do
Paper-based MARs are
error prone
Patients are often difficult
to locate and/or identify
Monitoring
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Loosely coupled system
leading to poor
monitoring
Minimum monitoring
frequency for many
medications doesn’t exist
Consultant pharmacist
monthly review
(retrospective)
Handler SM, Am J Geriatr Pharmacother, 2004
A Conceptual Model for Medication-Related Problems in Older Adults
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Definitions of Medication Error (ME)
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any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the health care
professional, or consumer
American J of Health-System Pharmacy 1998; 55(2):165-6
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preparation or administration of medications which is not
in accordance with physician orders or manufacturers
instructions (F-Tag 332)
an error in the prescribing, order communication,
dispensing, administering, or monitoring phase(s) of the
medication use process.
ME Reporting in Nursing Homes
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Setting:
 A single nonprofit, community-based NH
Methods/Case-Finding:
 ME reports submitted over a 21-month period
Outcome:
 ME reports containing the step in medication use process
where the ME occurred, the type of ME, and the therapeutic
class involved
Results:
 88 ME reports were submitted (4.7/mo.) with 68% occurring
at the administration stage and 20% at the dispensing stage
Conclusions:
 There is gross underreporting of MEs in the NH setting and
the reasons for this is not well characterized
Handler S, et. al., Am J Ger Pharmacother 2004;2:190-196.
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Suboptimal Prescribing in Older Adults
1.
Overutilization (i.e., polypharmacy)
2.
Inappropriate utilization
3.
Underutilization
Hanlon JT, et al. J Am Geriatr Soc 2001;49:200-9.
Overutilization of Medications
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Can be defined in the following two ways:
1. The concomitant use of multiple drugs, which is
measured by a simple count of medications
(Defined by CMS as > 9 medications)
2. The administration of more medications than are
clinically indicated
Stewart RB. DICP 1990;24(3):321-3; Montamat SC, et al. Clinics
in Geriatric Medicine 1992;8(1):143-58
Medication Use in U.S. NHs (n=328)
Med. Type
Routine
Prn
9+ meds
Neuroleptics
Antidepressants
Anxiolytics
Hypnotics
Mean / %
6.69 +/- 1.12
2.61 +/- 1.35
27.1%
16.9 %
34.5 %
10.1 %
2.3 %
Tobias DE, Sey M. Consult Pharm 2001;16:54-64.
Inappropriate Use of Medications
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Can be defined in the following two ways:
1. Prescribing medications that have more potential
risk than potential benefit
2. Prescribing that does not agree with accepted
medical standards
Gurwitz JH. JAMA 1994;272(4):316-7; Schmader K, et al. Journal of the
American Geriatrics Society 1994;42(12):1241-7; Beers MH, et al.
Archives of Internal Medicine 1991;151(9):1825-32.
18
Underutilization of Drugs
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Undiagnosed and untreated condition (e.g., depression)
Diagnosed condition but omitted treatment (e.g., failure
to use a Beta-blocker after a heart attack)
Underuse of preventive treatment (e.g., vaccinations)
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Administration Errors in Nursing Homes
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Setting:
 36 healthcare institutions, 12 of which were NHs in
two states (Colorado and Georgia)
Methods/Case-Finding:
 Direct observation of healthcare provider during the
administration of medications
Outcome:
 MEs operationalized as a discrepancy between doses
administered and ordered
Results:
 The mean error rate was 19% (605 of 3216 doses
administered) and did not differ across institutions
 Most frequent errors by category: Wrong time
(43%)> omission (30%)> wrong dose (17%)
Barker KN, et al. Archives of Internal Medicine. 2002;162(16) :1897-903.
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Monitoring Errors in NHs
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Monitoring errors are probably the most common type of
error in [most clinical] settings, but are much more
difficult to identify, and no study was found…
Institute of Medicine. Preventing Medication Errors. 2006
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
WHO/Naranjo Model of Adverse Drug Reactions
Adverse Event
(AE)
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Adverse Drug Event
(ADE)
Adverse Drug Reaction
(ADR)
Adverse Events (AEs) are negative patient events that
are expressed as symptoms, signs or laboratory
abnormalities (Naranjo, Shear et al. 1992).
When a relationship between the adverse event and a
drug is suspected and plausible, then an Adverse Drug
Event (ADE) is assumed.
When an ADE is determined to be causally related to a
drug, then an Adverse Drug Reaction (ADR) is assumed.
Thus, an ADR will be defined as a noxious and
unintended patient event caused by a drug (Venulet and
ten Ham 1996; Edwards and Aronson 2000).
Consequences of ADRs
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Increased morbidity,
mortality, and decline in
functional status:
 Falls and fractures
 Malnutrition
Increased HealthServices
 Dehydration
Utilization
 Incontinence
 Sedation/Confusion
 Delirium
 Cognitive impairment
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Increased hospitalization:
 332 NH residents followed
for 4y
 64 ADE-associated
hospitalizations
Increased cost:
 For every dollar spent on
drugs in NHs, $1.33 in
health care resources are
consumed in the Tx of
drug-related problems
Cooper, South Med J. 1999;
92:485-90/Bootman, Arch Intern
Med. 1997; 157:2089-96
ADRs in the NH-Setting
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Setting:
 2 academic NHs
Methods/Case-Finding:
 Chart review, staff reports, and computerized signals
Outcome:
 ADR
Results:
 Over a 9-month period, 815 ADRs were identified, an
incidence rate of 9.8 ADRs per 100 patient-months
 Nearly 27.6% of the ADRs were fatal, life threatening
or serious, and 42% were preventable.
 Among the 338 preventable adverse drug events,
errors occurred most commonly at the ordering (n=
198 [59%]) and monitoring (n= 271 [80%]) stages
Gurwitz JH, et al. American Journal of Medicine. Mar
2005;118(3):251-258.
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Therapeutic Failure (TF)
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Failure to accomplish the goals of treatment
resulting from inadequate or inappropriate drug
therapy and not related to the natural progression
of disease
Can occur when:
 Omit a dose of a necessary medication
 Prescribe too low a dose of a necessary
medication
 A drug-drug interaction reduces the dose of a
medication
 Take a sub-therapeutic dose of a medication
(i.e., patient non-adherence)
Grymonpre R, et al. J Am Geriatr Soc 1988;36:1092-1098;
Hallas J, et al. Dan Med Bull 1991;38:417-20.1992
TFs in Older Hospitalized Inpatients
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Setting:
 Single 1,100 bed acute care facility
Methods/Case-Finding and causality:
 Chart review and Bergman algorithm
Outcomes:
 TFs
Results:
 31 TFs among a total of 162 patients whom
experienced an medication-related problem over a 4month period
Grymonpre RE, et al. J Am Geriatric Soc 1988;36(12):1092-8.
A Conceptual Model for Medication-related Problems in Older Adults.
Medication Use Process
Prescribing
Adverse Drug Reactions
Order
communication
Dispensing
Therapeutic
Failures
Administering
Monitoring
(Handler SM, et al,
AJGP 2006;4:264-272)
Medication Errors
Adverse Drug
Withdrawal
Events
Medication-Related Adverse
Patient Events
Adverse Drug Withdrawal Events (ADWE)
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a clinical set of signs or symptoms that are related to the
removal of a drug
Gerety JAGS, 1993 41(12): 1326-32.
ADWEs in the NH Setting
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Setting:
 Single VA-affiliated NH
Methods/Case-Finding and causality:
 Chart review
Outcomes:
 ADWEs
Results:
 201 ADRs in 95 residents, while 62 residents
experienced 94 ADWEs over an 18-month period
Gerety M et al. J Am Geriatric Soc 1993;41:1326-1332
Potential Solutions
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Improve medication monitoring for residents taking narrow
therapeutic index medications or medications that have
frequently been associated with adverse drug reactions
Improve your understanding and incorporation of the F-329
and F-428 interpretative guidelines into clinical practice
Report medication-related problems in your facilities to improve
intra and inter-institutional learning and prevent future
recurrence of similar events
Participate in an ongoing medication monitoring study that we
are conducting for members of the AMDA Research Network,
ASCP, or NCGNP.