by Donna Miller, DO Director, Geriatrics Institute St. Luke’s Hospital & Health Network

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Geriatric Education Center of Greater Geriatric Education Center of Greater PhiladelphiaPhiladelphiaGeriatric Education Center of Greater Geriatric Education Center of Greater PhiladelphiaPhiladelphia

When Wrong Things When Wrong Things Happen with Medications: Happen with Medications:

Risk and Prevention – Risk and Prevention – The Role of the Medication Team in Preventing and The Role of the Medication Team in Preventing and

Managing Problems with MedicationsManaging Problems with Medications

by

Donna Miller, DODonna Miller, DODirector, Geriatrics InstituteDirector, Geriatrics Institute

St. Luke’s Hospital & Health NetworkSt. Luke’s Hospital & Health NetworkBethlehem, PABethlehem, PA

Reviewed and updated, Fall 2006 Reviewers: Johanne Louis-Taylor, MSN, CRNP and GEC Series Editors

Reviewed and updated, Spring 2012 Reviewers: Donna M.Lisi, PharmD, BCPS, BCPP and Tamara Zurakowski, PhD, GNP-BC

© 2012 © 2012 University of Pennsylvania University of Pennsylvania Geriatric Education Center of Greater PhiladelphiaGeriatric Education Center of Greater Philadelphia

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Learning ObjectivesAt the end of this module you will be able

to:1. Describe common factors that are associated with ADEs2. Describe best drug prescribing practices for nursing homes and other long term care settings3. Describe the core and supportive roles ofhealth care professionals and caregivers in medication management.4. Describe a quality improvement approach to preventing, recognizing, and managing ADEs.


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Adverse Drug Event Adverse Drug Event (ADE)(ADE)

What is an Adverse Drug Event?

An adverse drug event is

“an injury resulting from the use of a drug”


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Adverse Drug Event Adverse Drug Event (ADE)(ADE)

Why pay attention to ADEs?Many people suffer injuries and even

death from ADEs each year• About one-half of ADEs are

preventable, especially the more serious ones

• Nursing Homes have high rates of ADEs: nearly 2 million each year in the U.S.

• Older adults in community settings: 2/3 make errors with their medications


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Most Common and Preventable ADEs in Community Settings

• Altered Kidney Function (e.g. abnormal levels of waste products, dehydration)

• Changes in GI Tract (abdominal pain, diarrhea, constipation)

• Bleeding

• High or low blood glucose


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Most Common and Preventable ADEs in

Nursing Homes• Altered Kidney Function (e.g. abnormal

levels of waste products, dehydration)• Changes in GI Tract (abdominal pain,

diarrhea, constipation)• Bleeding• High or low blood glucose• Mental status changed (confusion,

oversedation, delirium) – Particularly related to use of psychotropic

medications


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Factors Related to High Rates of ADEs in Community Settings

• Polypharmacy

• Complex medication instructions

• New and unfamiliar medications because of recent change in medical status

• Unclear discharge information- to continue or not to continue a prior medication


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Factors Related to High Rates of ADEs in Nursing

Homes• Prescribing (wrong dose, wrong drug)

• Transcription (transferring orders manually onto med sheet)

• Dispensing (from pharmacy to facility)

• Drug administration (actual delivery to patient)

• Monitoring (not recognizing signs of unexpected drug response)


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Which Older Persons Are Most At Risk for

ADE’s?• Persons taking more medications

• Persons taking drugs from several categories

• Persons taking specific classes of medications (on next slide)


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Medications with High Rates of ADEs

Medication; Class ADE Prevention Strategies

Anti-coagulants, Warfarin

Drug-drug interactions; Bleeding

Verify medications and doses; regular blood work

Insulin Hypoglycemia-related falls

Do not use sliding scale “coverage”

Digoxin Toxicity Limit total daily dose to 0.125 mg

Anti-Psychotics Confusion, altered mental status

Ascertain need for medication, monitor response

Diuretics Electrolyte imbalance Keep older adult well-hydrated


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Drug Use Among Older Drug Use Among Older PersonsPersons

In the community

Average 8 drugs per older adult

Includes both prescription and over the counter medications

In nursing homes

Average 8 scheduled drugs per resident

Additional 3 PRN

medications per resident

40% of all residents

use ≥ 9 medications One-half (50%) are

“prn” drugs


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Why So Many Meds?Why So Many Meds?

• Older persons have multiple chronic medical conditions

• Pressure to prescribe• Fragmented

assessment and care• Treating the symptoms

rather than the underlying problem


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Potentially Inappropriate Medications In Older Adults• The Beers Criteria – American

Geriatrics Society, 2012– Medications that have a high risk of side

effects or limited therapeutic effects in older adults

– Medications that may exacerbate existing diseases or conditions

– Medications that may be the best choice for the older adult, but have associated risks


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Common Serious Medication Interactions Among Older Adults

• Warfarin– NSAIDS

– Sulfa

– Macrolides

– Quinolones

– Phenytoin

• ACE Inhibitors– Potassium supplements

– spironolactone

• Digoxin– Amiodarone

– Verapamil

• Theophylline– Quinolones


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Medication Reconciliation in Long-Term Care

• Verification– Collect medication history

• Clarification– Check medications, doses, and

instructions

• Reconciliation– Document changes in orders


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Who’s on the Medication Team?

• Family

• Dietitian

• Social Worker

• Physical Therapist

• Occupational Therapist

• Activities Therapists

• Prescriber (Physician, NP, or PA)

• Nurse

• Pharmacist

• Direct Care Staff (CNA, personal care aide, etc.)

• Patient/Resident


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All Team Members Are Alert to the Five Rights

• Right Patient

• Right Drug

• Right Dose

• Right Time

• Right Route


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Medication Team: Prescribing Physician, NP, or

PA Use best prescribing practices

• Select the best drug or combination for condition

• Start low, go slow, but go!• Avoid drug-drug interactions• Avoid potential drug-disease

interactions

Monitor drugs and patient reaction as needed


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Medication Team: Prescribing Physician, NP, or

PAMore Best Practices in the Long-Term Care setting:•Verify the need for each drug•Record reason for each drug•Record results of drug monitoring•The Consulting Pharmacists are your best friends•Be aware of federal and state regulations regarding prescribing


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The Well-Written Medication Order

• Written for a limited number of days

• Includes daily frequency, not by specific hours

• Specifies indication for PRN orders

• Consideration of cost one factor in selecting medications


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Medication Team: Nurse

• Administer medications• Inform CNAs of drug changes

and possible side effects• Encourage CNA reporting• Educate patients about

medications and how to report problems

• Use best nursing practices• Assess the older adult• Safeguard against potential

errors


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Nursing Assessment

• Vital Signs– Orthostatic BP and Pulse

• Mental Status

• GI system

• Falls


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Documentation

• Changes in behavior, signs, or symptoms

• Monitoring efforts and results of assessments

• Actions taken in relation to findings, and older adult’s response


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Medication Team:Medication Team: Direct Care Staff Direct Care Staff

• Observe patients for reactions to medication changes

• Report changes in patients to nurses

• Provide direct care following best practice guidelines

• Work in your team to solve medication problems


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Observations by the CNA

• Changes in appetite and intake

• Changes in behavior

• Changes in bowel and bladder patterns

• Changes in functional status

• Changes in skin

• Changes in sleep patterns

• Changes in thinking or memory


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Medication Team: Pharmacist

• Perform periodic drug review• Safeguard against potential errors• Work as a member of the team• Educate team members• Recommend medication

documentation standards• Recommend emergency medication

supplies• Replace emergency medications as

needed• Recommend appropriate reference

materials


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Medication Team: Patients and Families

• Communicate new complaints to caregivers and health care team

• Learn about their current and new medications

• Check medicines each time they are taken

• Report any new behaviors or problems when medications are taken


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Medication Team and QI

• In any setting with a QI process, be involved in monitoring and problem solving

• Refer medication problems to QI team

• Involve all medication team members in identifying root causes of problems


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Videotape “When Wrong Things Happen…”

The first segment of this video contains

two scenes. Please watch the segment

with these questions in mind:• Do you see examples of good

nursing practice?

• Do you see circumstances that could lead to adverse drug events?


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Videotape “When Videotape “When Wrong Wrong

Things Happen…”Things Happen…”The second segment of this video shows a

QI team meeting about the medication

event involving Mrs. Saeger.How does each of the team members contribute to solving the problem?

• Administrator• Consulting pharmacist• Nurse• Direct Care Staff (CNA)


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Learning Objectives:Did we meet them?Are you now able to:1. Describe common causes of adverse

drug events?2. Describe best drug prescribing practices?3. Describe roles of 4 health care

professionals and caregivers in medication management?

4. Describe a quality improvement approach to preventing adverse drug events?


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Leadership and Staff:

Lois K. Evans, DNSc, RN, FAANSeries Associate Editor Viola MacInnes IndependenceProfessorSchool of Nursing University of Pennsylvania

Sangeeta BhojwaniAssociate Director, Series Assistant EditorDVGECUniversity of Pennsylvania

Kathleen Egan, PhD Series EditorDVGEC Program Administrator Director, DVGEC University of Pennsylvania

Mary Ann Forciea, MDSeries Associate EditorClinical Associate Professor of MedicineDivision of Geriatric Medicine, University of Pennsylvania


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Thank you for your attention!

The End

by Donna Miller, DO Director, Geriatrics Institute St. Luke’s Hospital & Health Network

Documents

Transcript of by Donna Miller, DO Director, Geriatrics Institute St. Luke’s Hospital & Health Network