Medication-Related Problems in the Nursing Home Setting Steven M. Handler, MD, MS, CMD Department of...

Medication-Related Medication-Related Problems in the Nursing Problems in the Nursing

Home SettingHome SettingSteven M. Handler, MD, MS, CMDSteven M. Handler, MD, MS, CMD

Department of Medicine,Department of Medicine,Division of Geriatric MedicineDivision of Geriatric Medicine

and Department of Biomedical and Department of Biomedical InformaticsInformatics

ObjectivesObjectives

Describe the medication use process in the Describe the medication use process in the nursing home settingnursing home setting

Provide a conceptual framework for medication-Provide a conceptual framework for medication-related problemsrelated problems

Discuss the epidemiology and impact of Discuss the epidemiology and impact of medication-related problemsmedication-related problems

Present current and future solutions for Present current and future solutions for medication-related problemsmedication-related problems

Kohn, National Academy Press. 2Kohn, National Academy Press. 2000000

To Err is Human: Building a Safer To Err is Human: Building a Safer Healthcare SystemHealthcare System

This report focused national attention on the This report focused national attention on the quality of care and prevalence of medical errors quality of care and prevalence of medical errors in the healthcare systemin the healthcare system

Largest proportion of medical errors are Largest proportion of medical errors are medication-relatedmedication-related

Overwhelming majority of patient-safety Overwhelming majority of patient-safety initiatives introduced to address concerns raised initiatives introduced to address concerns raised in this report have been geared toward acute-in this report have been geared toward acute-carecare

Medications: A Love-Hate Medications: A Love-Hate RelationshipRelationship

Geriatricians and their patients rely heavily on Geriatricians and their patients rely heavily on pharmacotherapy to palliate symptoms, improve pharmacotherapy to palliate symptoms, improve functional status and quality of life, cure or functional status and quality of life, cure or manage disease, and prolong survivalmanage disease, and prolong survival

Medications are the most frequently used and Medications are the most frequently used and misused form of therapymisused form of therapy

The benefits of medication therapy in older adults The benefits of medication therapy in older adults are counterbalanced by the problems that they are counterbalanced by the problems that they posepose

PrescribingPrescribing

Complex medical Complex medical patientspatients

Polypharmacy is the rule Polypharmacy is the rule rather than the exceptionrather than the exception

Lack of evidence-base for Lack of evidence-base for prescribing most prescribing most medicationsmedications

Frequent lack of facility-Frequent lack of facility-specific medication specific medication formularies/Part D issuesformularies/Part D issues

Documenting/Order Documenting/Order CommunicationCommunication

Use of paper records and faxing of medication Use of paper records and faxing of medication requests to pharmacies is the rule rather then the requests to pharmacies is the rule rather then the exceptionexception

Frequent use of verbal (oral) ordersFrequent use of verbal (oral) orders

Process that often requires the nurse to act as an Process that often requires the nurse to act as an “agent” of the prescriber“agent” of the prescriber

DispensingDispensing Often no on-site pharmacyOften no on-site pharmacy

Cycle/batch filling of Cycle/batch filling of medications monthly in medications monthly in blister packsblister packs

Often several different Often several different pharmacies deliver pharmacies deliver medications to patientsmedications to patients

Pharmacy delivery schedule Pharmacy delivery schedule is often once a day and an is often once a day and an e-box is available for e-box is available for emergent medication needsemergent medication needs

AdministeringAdministering

Medication pass is one Medication pass is one of many tasks that of many tasks that nursing staff are asked nursing staff are asked to doto do

Paper-based MARs are Paper-based MARs are error proneerror prone

Patients are often Patients are often difficult to locate difficult to locate and/or identifyand/or identify

MonitoringMonitoring

Loosely coupled system Loosely coupled system leading to poor leading to poor monitoringmonitoring

Minimum monitoring Minimum monitoring frequency for many frequency for many medications doesn’t existmedications doesn’t exist

Consultant pharmacist Consultant pharmacist monthly review monthly review (retrospective)(retrospective)

Handler SM, Am J Geriatr Pharmacother, 2004

A Conceptual Model for Medication-Related Problems in Older Adults

Adverse Drug Reactions

Medication Use Process

Adverse Drug Withdrawal

Events

Therapeutic Failures

Ordercommunication

Dispensing

Administering

Monitoring

Prescribing

Medication ErrorsMedication-Related Adverse

Patient Events

(Handler SM, et al, AJGP 2006;4:264-272)

Definitions of Medication Error Definitions of Medication Error (ME)(ME)

any preventable event that may cause or lead to any preventable event that may cause or lead to inappropriate medication use or patient harm inappropriate medication use or patient harm while the medication is in the control of the while the medication is in the control of the health care professional, or consumerhealth care professional, or consumer

American J of Health-System Pharmacy 1998; 55(2):165-6American J of Health-System Pharmacy 1998; 55(2):165-6

preparation or administration of medications preparation or administration of medications which is not in accordance with physician orders which is not in accordance with physician orders or manufacturers instructions (F-Tag 332)or manufacturers instructions (F-Tag 332)

an error in the prescribing, order communication, an error in the prescribing, order communication, dispensing, administering, or monitoring phase(s) dispensing, administering, or monitoring phase(s) of the medication use process.of the medication use process.

ME Reporting in Nursing HomesME Reporting in Nursing Homes Setting:Setting:

A single nonprofit, community-based NHA single nonprofit, community-based NH Methods/Case-Finding:Methods/Case-Finding:

ME reports submitted over a 21-month periodME reports submitted over a 21-month period Outcome:Outcome:

ME reports containing the step in medication use ME reports containing the step in medication use process where the ME occurred, the type of ME, and process where the ME occurred, the type of ME, and the therapeutic class involvedthe therapeutic class involved

Results:Results: 88 ME reports were submitted (4.7/mo.) with 68% 88 ME reports were submitted (4.7/mo.) with 68%

occurring at the administration stage and 20% at the occurring at the administration stage and 20% at the dispensing stagedispensing stage

Conclusions:Conclusions: There is gross underreporting of MEs in the NH There is gross underreporting of MEs in the NH

setting and the reasons for this is not well setting and the reasons for this is not well characterizedcharacterizedHandler S, et. al., Am J Ger Pharmacother 2004;2:190-196.Handler S, et. al., Am J Ger Pharmacother 2004;2:190-196.

A Conceptual Model for Medication-related Problems in Older Adults.




Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Suboptimal Prescribing in Older Suboptimal Prescribing in Older AdultsAdults

1.1. Overutilization (i.e., polypharmacy)Overutilization (i.e., polypharmacy)

2.2. Inappropriate utilizationInappropriate utilization

3.3. UnderutilizationUnderutilization

Hanlon JT, et al. J Am Geriatr Soc Hanlon JT, et al. J Am Geriatr Soc 2001;49:200-9.2001;49:200-9.

Overutilization of MedicationsOverutilization of Medications

Can be defined in the following two ways:Can be defined in the following two ways:

1.1. The concomitant use of multiple drugs, which The concomitant use of multiple drugs, which is measured by a simple count of medicationsis measured by a simple count of medications(Defined by CMS as (Defined by CMS as >> 9 medications) 9 medications)

2.2. The administration of more medications than The administration of more medications than are clinically indicatedare clinically indicated

Stewart RB. DICP 1990;24(3):321-3; Montamat SC, et al. Stewart RB. DICP 1990;24(3):321-3; Montamat SC, et al. Clinics in Geriatric Medicine 1992;8(1):143-58Clinics in Geriatric Medicine 1992;8(1):143-58

Medication Use in U.S. NHs Medication Use in U.S. NHs (n=328)(n=328)

Med. TypeMed. Type Mean / %Mean / %Routine Routine 6.69 +/- 1.126.69 +/- 1.12PrnPrn 2.61 +/- 1.352.61 +/- 1.359+ meds9+ meds 27.1%27.1%NeurolepticsNeuroleptics 16.9 %16.9 %AntidepressantsAntidepressants 34.5 %34.5 %AnxiolyticsAnxiolytics 10.1 %10.1 %HypnoticsHypnotics 2.3 % 2.3 %

Tobias DE, Sey M. Consult Pharm 2001;16:54-64.Tobias DE, Sey M. Consult Pharm 2001;16:54-64.

1818

Inappropriate Use of MedicationsInappropriate Use of Medications

Can be defined in the following two ways:Can be defined in the following two ways:

1.1. Prescribing medications that have more Prescribing medications that have more potential risk than potential benefitpotential risk than potential benefit

2.2. Prescribing that does not agree with Prescribing that does not agree with accepted medical standardsaccepted medical standards

Gurwitz JH. JAMA 1994;272(4):316-7; Schmader K, et al. Gurwitz JH. JAMA 1994;272(4):316-7; Schmader K, et al. Journal of the American Geriatrics Society 1994;42(12):1241-Journal of the American Geriatrics Society 1994;42(12):1241-7; Beers MH, et al. Archives of Internal Medicine 7; Beers MH, et al. Archives of Internal Medicine 1991;151(9):1825-32.1991;151(9):1825-32.

Underutilization of DrugsUnderutilization of Drugs

Undiagnosed and untreated condition (e.g., Undiagnosed and untreated condition (e.g., depression)depression)

Diagnosed condition but omitted treatment (e.g., Diagnosed condition but omitted treatment (e.g., failure to use a Beta-blocker after a heart attack)failure to use a Beta-blocker after a heart attack)

Underuse of preventive treatment (e.g., Underuse of preventive treatment (e.g., vaccinations)vaccinations)





Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Administration Errors in Nursing HomesAdministration Errors in Nursing Homes Setting:Setting:

36 healthcare institutions, 12 of which were NHs 36 healthcare institutions, 12 of which were NHs in two states (Colorado and Georgia)in two states (Colorado and Georgia)

Methods/Case-Finding:Methods/Case-Finding: Direct observation of healthcare provider during Direct observation of healthcare provider during

the administration of medicationsthe administration of medications Outcome:Outcome:

MEs operationalized as a discrepancy between MEs operationalized as a discrepancy between doses administered and ordereddoses administered and ordered

Results:Results: The mean error rate was 19% (605 of 3216 doses The mean error rate was 19% (605 of 3216 doses

administered) and did not differ across institutionsadministered) and did not differ across institutions Most frequent errors by category: Wrong time Most frequent errors by category: Wrong time

(43%)> omission (30%)> wrong dose (17%)(43%)> omission (30%)> wrong dose (17%)

Barker KN, et al. Archives of Internal Medicine. 2002;162(16) :1897-Barker KN, et al. Archives of Internal Medicine. 2002;162(16) :1897-903.903.





Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Monitoring Errors in NHsMonitoring Errors in NHs

Monitoring errors are probably the most common Monitoring errors are probably the most common type of error in [most clinical] settings, but are type of error in [most clinical] settings, but are much more difficult to identify, and no study was much more difficult to identify, and no study was found…found…

Institute of Medicine. Institute of Medicine. Preventing Medication ErrorsPreventing Medication Errors. 2006. 2006





Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Adverse EventsAdverse Events (AEs) are negative patient events (AEs) are negative patient events that are expressed as symptoms, signs or laboratory that are expressed as symptoms, signs or laboratory abnormalities (Naranjo, Shear et al. 1992).abnormalities (Naranjo, Shear et al. 1992).

When a relationship between the adverse event and When a relationship between the adverse event and a drug is suspected and plausible, then an a drug is suspected and plausible, then an Adverse Adverse Drug EventDrug Event (ADE) is assumed. (ADE) is assumed.

When an ADE is determined to be causally related to When an ADE is determined to be causally related to a drug, then an a drug, then an Adverse Drug ReactionAdverse Drug Reaction (ADR) is (ADR) is assumed. Thus, an ADR will be defined as a noxious assumed. Thus, an ADR will be defined as a noxious and unintended patient event caused by a drug and unintended patient event caused by a drug (Venulet and ten Ham 1996; Edwards and Aronson (Venulet and ten Ham 1996; Edwards and Aronson 2000).2000).

Adverse Event(AE)

Adverse Drug Event(ADE)

Adverse Drug Reaction(ADR)

WHO/Naranjo Model of Adverse Drug ReactionsWHO/Naranjo Model of Adverse Drug Reactions

Cooper, South Med J. 1999; 92:4Cooper, South Med J. 1999; 92:485-90/Bootman, Arch Intern Med. 85-90/Bootman, Arch Intern Med. 1997; 157:2089-961997; 157:2089-96

Consequences of ADRsConsequences of ADRs

Increased Increased morbiditymorbidity, , mortalitymortality, and decline , and decline in in functional statusfunctional status:: Falls and fracturesFalls and fractures MalnutritionMalnutrition DehydrationDehydration IncontinenceIncontinence Sedation/ConfusionSedation/Confusion DeliriumDelirium Cognitive Cognitive

impairmentimpairment

Increased Increased hospitalizationhospitalization:: 332 NH residents 332 NH residents

followed for 4yfollowed for 4y 64 ADE-associated 64 ADE-associated

hospitalizationshospitalizations Increased Increased costcost::

For every dollar spent For every dollar spent on drugs in NHs, $1.33 on drugs in NHs, $1.33 in health care resources in health care resources are consumed in the Tx are consumed in the Tx of drug-related problemsof drug-related problems

Increased Health-Services

Utilization

ADRs in the NH-SettingADRs in the NH-Setting Setting:Setting:

2 academic NHs2 academic NHs Methods/Case-Finding:Methods/Case-Finding:

Chart review, staff reports, and computerized signalsChart review, staff reports, and computerized signals Outcome:Outcome:

ADRADR Results:Results:

Over a 9-month period, 815 ADRs were identified, an Over a 9-month period, 815 ADRs were identified, an incidence rate of incidence rate of 9.89.8 ADRs per 100 patient‑months ADRs per 100 patient‑months

Nearly 27.6% of the ADRs were fatal, life threatening Nearly 27.6% of the ADRs were fatal, life threatening or serious, and 42% were preventable.or serious, and 42% were preventable.

Among the 338 preventable adverse drug events, Among the 338 preventable adverse drug events, errors occurred most commonly at the ordering (n= errors occurred most commonly at the ordering (n= 198 [59%]) and monitoring (n= 271 [80%]) stages198 [59%]) and monitoring (n= 271 [80%]) stages

Gurwitz JH, et al. Gurwitz JH, et al. American Journal of Medicine. American Journal of Medicine. MarMar2005;118(3):251-258.2005;118(3):251-258.





Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Therapeutic Failure (TF)Therapeutic Failure (TF)

Failure to accomplish the goals of treatment Failure to accomplish the goals of treatment resulting from inadequate or inappropriate resulting from inadequate or inappropriate drug therapy and not related to the natural drug therapy and not related to the natural progression of diseaseprogression of disease

Can occur when:Can occur when: Omit a dose of a necessary medicationOmit a dose of a necessary medication Prescribe too low a dose of a necessary Prescribe too low a dose of a necessary

medicationmedication A drug-drug interaction reduces the A drug-drug interaction reduces the

dose of a medicationdose of a medication Take a sub-therapeutic dose of a Take a sub-therapeutic dose of a

medication (i.e., patient non-adherence)medication (i.e., patient non-adherence)

Grymonpre R, et al. J Am Geriatr Soc 1988;36:1092-Grymonpre R, et al. J Am Geriatr Soc 1988;36:1092-1098; 1098;

Hallas J, et al. Dan Med Bull 1991;38:417-20.1992Hallas J, et al. Dan Med Bull 1991;38:417-20.1992

TFs in Older Hospitalized TFs in Older Hospitalized InpatientsInpatients

Setting:Setting: Single 1,100 bed acute care facilitySingle 1,100 bed acute care facility

Methods/Case-Finding and causality:Methods/Case-Finding and causality: Chart review and Bergman algorithmChart review and Bergman algorithm

Outcomes:Outcomes: TFsTFs

Results:Results: 31 TFs among a total of 162 patients whom 31 TFs among a total of 162 patients whom

experienced an medication-related problem experienced an medication-related problem over a 4-month periodover a 4-month period

Grymonpre RE, et al. J Am Geriatric Soc Grymonpre RE, et al. J Am Geriatric Soc 1988;36(12):1092-8.1988;36(12):1092-8.





Events


Ordercommunication

Dispensing

Administering

Monitoring

Prescribing


Patient Events


Adverse Drug Withdrawal Events Adverse Drug Withdrawal Events (ADWE)(ADWE)

a clinical set of signs or symptoms that are a clinical set of signs or symptoms that are related to the removal of a drugrelated to the removal of a drug

Gerety JAGS, 1993 41(12): 1326-Gerety JAGS, 1993 41(12): 1326-32.32.

ADWEs in the NH SettingADWEs in the NH Setting

Setting:Setting: Single VA-affiliated NHSingle VA-affiliated NH

Methods/Case-Finding and causality:Methods/Case-Finding and causality: Chart reviewChart review

Outcomes:Outcomes: ADWEsADWEs

Results:Results: 201 ADRs in 95 residents, while 62 residents 201 ADRs in 95 residents, while 62 residents

experienced 94 ADWEs over an 18-month periodexperienced 94 ADWEs over an 18-month periodGerety M et al. J Am Geriatric Soc 1993;41:1326-Gerety M et al. J Am Geriatric Soc 1993;41:1326-

13321332

Potential SolutionsPotential Solutions

Improve medication monitoring for residents taking narrow Improve medication monitoring for residents taking narrow therapeutic index medications or medications that have therapeutic index medications or medications that have frequently been associated with adverse drug reactionsfrequently been associated with adverse drug reactions

Improve your understanding and incorporation of the F-329 Improve your understanding and incorporation of the F-329 and F-428 interpretative guidelines into clinical practiceand F-428 interpretative guidelines into clinical practice

Report medication-related problems in your facilities to Report medication-related problems in your facilities to improve intra and inter-institutional learning and prevent improve intra and inter-institutional learning and prevent future recurrence of similar eventsfuture recurrence of similar events

Participate in an ongoing medication monitoring study that Participate in an ongoing medication monitoring study that we are conducting for members of the AMDA Research we are conducting for members of the AMDA Research Network, ASCP, or NCGNP.Network, ASCP, or NCGNP.

Medication-Related Problems in the Nursing Home Setting Steven M. Handler, MD, MS, CMD Department of...

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