Transcript Medication Errors in the Clinic

Medication Errors in the Clinic
February 24, 2009
Dave Tanaka
Objectives
 Review the epidemiology of medication
errors
 Review the common causes of medication
errors
 Review strategies to decrease medication
errors
Definitions
Error - Failure of a planned action to be
completed as intended or the use of a
wrong plan to achieve that aim
Error of commission - taking the wrong
action
Error of omission - failing to take action
Definitions
Adverse Drug Event (ADE) - injury resulting
from drug therapy
Preventable Adverse Drug Event (pADE)
pADE in Ambulatory Care
 Median ADE 14.9 / 1,000 person months
 pADE
5.6 / 1,000 person months
 pADE
requiring hosp0.45 / 1,000 person months
Ann Pharmacother 2007; 41:1411-26.
A 40-Year-Old Woman Who Noticed a Medication Error
David W. Bates
JAMA. 2001;285(24):3134-3140.
DR AUDET: Ms K is a 40-year-old woman who found an error
with her prescribed medications. She was diagnosed with
HIV infection in 1996 and has taken several different drug
regimens. Despite the complexity of her drug program, Ms
K has been able to manage it well. She has taken an active
role in understanding the benefits of her medications and
has not had major adverse effects.
Ms K had asked that refills for her prescriptions be called
in to her pharmacy. When the time came to take her newly
filled prescriptions, she noted that 2 of the drugs were
unfamiliar
to her, and that 2 of her HIV drugs were missing.
A 40-Year-Old Woman Who Noticed a Medication
Error
David W. Bates
JAMA. 2001;285(24):3134-3140.
Ms K immediately called her primary care physician,
Dr T, to report this fact and have the error rectified. She was
concerned about continuing her planned HIV regimen without
interruption. The error was confirmed: Stelazine (trifluoperazine)
and ranitidine had been dispensed to her
instead of stavudine and lamivudine.
The correct prescriptions were then called in to the pharmacy.
Fortunately, Ms K was able to continue her drug regimen
uninterrupted and did not experience any harm from
this event.
What type of error is this?
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Transcription
Dispensing
Prescription
Administration
11%
14%
49%
26%
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential
adverse drug events: implications for prevention. JAMA. 1995;274:29-34.
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Case #2
75 yo man with h/o CVA X 2, BPH, hypothyroidism,
depression and bladder cancer
Generally well, active, quit smoking after second CVA
about 2 years ago, depression started after first CVA
about 5 years ago, hypothyroid for about 10 years,
bladder cancer new but non-invasive
Meds: ASA + clopidogrel, dutastride + tamsulosin,
levothyroxine, venlafaxine, lovastatin and budesonide
nasal spray
Case #2
 He calls with 5 d h/o abd pain mild to
moderate, comes/goes, no recent illness, no n/v,
no diarrhea, and no urinary symptoms
 Nothing definitely makes it worse
 TUMs improve the pain for short period
Diagnosis?
How common are GI side effects from
NSAID’s
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60 % of regular users have dyspepsia or GERD
20-30% will have ulcers on EGD
2.5% - 4.5% will have symptomatic ulcers
1 -1.5% will have hemorrhage, perforation or
obstruction as complication of ulcer
How common are GI side effects from
NSAID’s
 Age >75 RR
 h/o PUD
10.6
12.5 -15.4
Jones, R, Rubin, G, Berenbaum, F, Scheim an, J. ŅGastrointestinal and cardiovascular
risks of nonsteroidal anti-inflammatory drugsÓ Am J Med 2008; 121: 464-74.
What do you recommend?
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The main risks for GI complications from NSAIDS are:
h/o PUD / bleeding
Age >70
Steroids or anticoagulants
 No risk factors - nonselective NSAID appropriate
 If GI risk factor - PPI / misoprostol + NSAID
Third Canadian Consensus conference group. J Rheumatol 2006; 33:14 0-57.
First international working party on gastrointestinal and cardiovascular effects of
nonsteroidal anti-inflamm atory drugs and anti-platelet agents. Am J Gastroenterol 2008;
103: 2908 -18.
Case #3
55 yo man calls from the airport in severe pain. He has
been unable to urinate for almost 2 days. He has no
previous medical history.
82 yo woman calls because she is not getting over her
URI. The URI started about 8 days ago and she is
feeling worse – tired, no energy but no fever, no cough,
no runny nose, no GI symptoms
h/o Htn, hyperlipidemia and hypothyroidism
What more do you want to know?
 The man flew into Chicago 2 days ago. He was
developing a cold so he bought Dimetapp at the
airport. He has not urinated since late that evening.
 The woman had severe running nose and congestion
with her URI. She has been taking Nyquil at night,
Dayquil and tylenol cold and sinus during the day.
 She said the nose is better but she feels lousy and tired.
She does not sound as though she has a sinus infection.
Anticholinergic side effects
 In a study looking at increasing anticholinergic
effects and whether they were associated with
increased side effects, there was a strong
correlation with increased report of side effects
with increasing anticholingeric risk scale.
Rud olph, JL, Salow, MJ, Angeli ni, MC, McGli nchey, RE. ŅThe anticholi nergic risk
scale and anticholi nergic adverse effects in older personsÓ Arch Intern Med 2008; 168:
508-13.
Updating the Beers Criteria for Potentially Inappropriate
Medication Use in Older Adults
Results of a US Consensus Panel of Experts
Donna M. Fick, PhD, RN; James W. Cooper, PhD, RPh;
William E. Wade, PharmD, FASHP, FCCP; Jennifer L.
Waller, PhD; J. Ross Maclean, MD; Mark H. Beers, MD
Arch Intern Med. 2003;163:2716-2724.
The application of the Beers criteria and other tools for
identifying potentially inappropriate medication use will
continue to enable providers to plan interventions for
decreasing both drug-related costs and overall costs
and thus minimize drug-related problems.
Potentially Inappropriate Medications for Individuals Age 65 Years or Older
Budnitz, D. S. et. al. Ann Intern Med 2007;147:755-765
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Medication Use Leading to Emergency Department Visits for Adverse Drug
Events in Older Adults
Daniel S. Budnitz, MD, MPH; Nadine Sheha b, PharmD; Scott R. Kegler, PhD;
and Chesley L. Richards, MD, MPH
4 December 2007 | Volume 147 Issue 11 | Pages 755-765
Ann Intern Med
3.6% of ED visits were related to medications on the Beers list
33.3% of ED visits were from 3 meds Š warfarin 17.3%, insulin 13% and digoxin 3.2%
Cases and national estimates of ED visits for ADE in person >65
Warfarin
Insulin
Aspirin
Clopidogrel
Digoxin
Glyburide
Acetaminophenhydrocodone
Cases
854
616
232
173
130
98
National estimate (%)
17.3
13.0
5.7
4.7
3.2
2.3
76
1.7
Potentially inappropriate medications
Anticholinergics
38
Nitrofurantoin
25
Propoxyphene
23
0.9
0.5
0.5
Medication Use Leading to Emergency Department Visits for
Adverse Drug Events in Older Adults
 Conclusion: Compared with other medications,
Beers criteria medications caused low numbers of
and few risks for emergency department visits for
adverse events. Performance measures and
interventions targeting warfarin, insulin, and
digoxin use could prevent more emergency
department visits for adverse events.
4 December 2007 | Volume 147 Issue 11 | Pages 755-765
Ann Intern Med
Case #4
 88 yo with htn, a fib, and multiple other
problems
 Need to renew the levothyroxine
 Since you work at University Medicine, you
click on the levothyroxine and hit renew
Drug-drug interaction
 Incidence of major interactions 0.6-23.3%
 6-30% of all ADE’s
 2.8% of hospitalizations
Potential drug–drug interactions within Veterans Affairs
medical centers
Methods. This study was a retrospective,
cross-sectional database analysis of
pharmacy records to assess the
prevalence of 25 clinically important DDIs.
Potential drug–drug interactions within Veterans Affairs medical
centers
Results. The study population included
2,795,345 patients who filled prescriptions
for medications involved in potential DDIs
across 128 VAMCs.
The overall rate of potential DDI in the VA was
21.54 per 1,000 veterans exposed to the
object or precipitant medication of interest.
Potential drug–drug interactions within Veterans Affairs medical
centers
The results of this study suggest that potential
DDI continue to be problematic even within
a health care system with computerized
prescriber order entry (CPOE) and
computerized alerts for interactions.
Am J Health sys pharm 2007; 64:1500-5.
Evaluation of an Electronic Critical Drug Interaction Program Coupled
with Active Pharmacist Intervention
METHODS: A physician and team of outpatient
pharmacists and clinical pharmacy staff
developed a condensed list of critical drug
interactions (8 drug combinations) to be included
in the evaluation of critical drug interaction alert
program (CDIX). Monthly electronic outpatient
pharmacy data were collected 20 months before
and 37 months after CDIX implementation, with
no lag period following implementation.
Evaluation of an Electronic Critical Drug Interaction Program Coupled
with Active Pharmacist Intervention
Critical interacting of Drug-drug combinations
Macrolides
carbamazepine, cyclosporin,
(clarithyro / erythro)
digoxin, theophylline
Phenytoin
cimetidine, fluconizole
Theophylline
cimetidine, ciprofloxacin
Critical drug interaction rate per 10,000 RX dispensed
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Proportion per 10,000 Prescriptions Dispensed
Drugs
Pre-Intervention Post-Intervention p Values
Macrolides
carbamazepine 17.0
7.3
<0.001
cyclosporine
1.8
1.7
0.74
digoxin
17.1
10.0
0.18
theophylline
24.7
6.9
<0.001
Phenytoin
cimetidine
5.3
2.6
0.07
fluconazole
13.5
8.6
0.54
Theophylline
cimetidine
5.8
2.5
0.05
ciprofloxacin
32.7
15.0
<0.001
Evaluation of an Electronic Critical Drug Interaction Program Coupled
with Active Pharmacist Intervention
CONCLUSIONS: Employing an intervention
system that limits electronic alerts
regarding drug interactions to those
deemed critical but that also requires
pharmacist intervention and collaboration
with the prescriber decreases the number
of critical drug interactions dispensed.
Ann Pharmacother 2007; 41:1979-85.
Case #5
 70 yo woman with long h/o Rheumatoid
arthritis presents to outside ED with fever
and hypotension. She is found to have
profoundly low WBC <1,000. Despite antibiotics, pressors and neupogen she dies 2
days later.
Case #5
 She had been on methotrexate for many
years, 12 mg IM weekly per VNS, no
change in meds, she had been asked to
take folic acid but per her family she did
not. Her last CBC was >4 months previous
and normal. She had refused blood draw
per VNS for CBC ordered Q6 weeks.
What type of error is this?
 Error of commission - The methotrexate is
an appropriate medication for RA and the
dosage is in the appropriate range for this
indication, so this is not an error of
commission.
 Error of omission - failure to take action or
monitoring
How could this error be prevented?
 No system for preventing this from happening in our
clinic at this time.
 I now have only 1 patient that I am responsible for his
methotrexate prescription. He has a limited script
requiring frequent refills. If he does not return for
regular visits and lab checks, he is called and his script
is not refilled unless he is compliant.
 (he recently has stopped the methotrexate)
How common are fatal medication errors?
 Cohort study of Medicare enrollees
 Mass 30,397 person years (7/99-6/00)
 11 deaths - 4 fatal bleeds, 1 PUD, 1
neuropenia, 1 hypoglycemia, 1 lithium, 1
digoxin, 1 complications of C diff
 5 permanent disability - 1 CVA, 2
intracranial bleeds, 1 pulm injury
 0.36 deaths per 1,000 person years
JAMA 2003; 289: 1107-16.
How common are fatal medication errors?
Multidisciplinary group examined all deaths
during a 2 year period of all admitted to
Dept of Med in Norway
732 deaths (5.2%) of 13,992 admissions
133 deaths (18.2%) directly or indirectly
associated with 1 or more drugs
9.5 deaths per 1000 hospitalized patients
Arch Intern Med 2001; 161: 2317-23
A Steep Increase in Domestic Fatal Medication Errors With Use of
Alcohol and/or Street Drugs
Methods We examined all US death
certificates from January 1, 1983, to
December 31, 2004 (N = 49 586 156),
particularly those with fatal medication
errors (FMEs) (n = 224 355).
A Steep Increase in Domestic Fatal Medication Errors With Use of
Alcohol and/or Street Drugs
Results The overall FME death rate
increased by 360.5% (1983-2004). This
increase far exceeds the increase in death
rates from adverse effects of medications
(33.2%) or from alcohol and/or street drugs
(40.9%). Thus, domestic FMEs combined
with alcohol and/or street drugs have
become an increasingly important health
problem compared with other FMEs.
Trends in the US death rate from fatal medication errors and from other causes of death (January
1, 1983-December 31, 2004)
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Copyright restrictions may apply.
Trends in the US Death Rate From FMEs and From Other Causes of Death, 1983 to 2004
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Copyright restrictions may apply.
Trends in the US fatal medication error (FME) death rate by type of circumstance in which the
FME occurs (A) and for various comparison groups (B) (January 1, 1983-December 31, 2004)
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Copyright restrictions may apply.
Trends in the US FME Death Rate by Type of Circumstance in Which the FME Occurs and for
Various Comparison Groups, 1983 to 2004a
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Copyright restrictions may apply.
Increase in US fatal medication error (FME) death rates by age group (A) and various
demographic characteristics (B) (January 1, 1983-December 31, 2004)
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Copyright restrictions may apply.
A Steep Increase in Domestic Fatal Medication Errors With Use of
Alcohol and/or Street Drugs
Conclusions These findings suggest that a
shift in the location of medication
consumption from clinical to domestic
settings is linked to a steep increase in
FMEs. It may now be possible to reduce
FMEs by focusing not only on clinical
settings but also on domestic settings.
Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566.
Medication errors in clinic
 Medication errors are common in clinic
 There are a variety of causes of these
errors
 Commission - wrong medication, dosage,
timing, etc
 Omission - inadequate monitoring or reaction
to symptoms or laboratory
 Systems - inadequate systems to prevent
these errors
Medication errors in clinic
 These errors are a significant cause of
morbidity and mortality
 EMR and electronic prescribing should
prevent most transcription errors but can
not be relied upon to prevent drug-drug
interactions
 Fatal Medication Errors are increasing
dramatically especially those associated
with alcohol and/or street drugs
Medication errors in clinic
 Obviously more research and better
understanding of these errors is needed
 Paradigm shift is required to improve
clinical outcomes and ensure the safety of
our patients