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Medication Errors in the Clinic February 24, 2009 Dave Tanaka.

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Presentation on theme: "Medication Errors in the Clinic February 24, 2009 Dave Tanaka."— Presentation transcript:

1 Medication Errors in the Clinic February 24, 2009 Dave Tanaka

2 Objectives Review the epidemiology of medication errors Review the common causes of medication errors Review strategies to decrease medication errors

3 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

4 Definitions Adverse Drug Event (ADE) - injury resulting from drug therapy Preventable Adverse Drug Event (pADE)

5 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.

6 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.

7 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.

8 What type of error is this? Transcription 11% Dispensing 14% Prescription49% Administration26% 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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10 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

11 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?

12 How common are GI side effects from NSAIDs 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

13 How common are GI side effects from NSAIDs Age >75 RR 10.6 h/o PUD 12.5 -15.4

14 What do you recommend? 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

15 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

16 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.

17 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.

18 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.

19 Budnitz, D. S. et. al. Ann Intern Med 2007;147:755-765 Potentially Inappropriate Medications for Individuals Age 65 Years or Older

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23 Cases and national estimates of ED visits for ADE in person >65 CasesNational estimate (%) Warfarin85417.3 Insulin61613.0 Aspirin232 5.7 Clopidogrel173 4.7 Digoxin130 3.2 Glyburide 98 2.3 Acetaminophen- hydrocodone 76 1.7 Potentially inappropriate medications Anticholinergics 38 0.9 Nitrofurantoin 25 0.5 Propoxyphene 23 0.5

24 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.

25 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

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27 Drug-drug interaction Incidence of major interactions 0.6-23.3% 6-30% of all ADEs 2.8% of hospitalizations

28 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.

29 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.

30 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.

31 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.

32 Evaluation of an Electronic Critical Drug Interaction Program Coupled with Active Pharmacist Intervention Critical interacting of Drug-drug combinations Macrolidescarbamazepine, cyclosporin, (clarithyro / erythro)digoxin, theophylline Phenytoincimetidine, fluconizole Theophyllinecimetidine, ciprofloxacin

33 Critical drug interaction rate per 10,000 RX dispensed

34 Proportion per 10,000 Prescriptions Dispensed DrugsPre-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 ciprofloxacin32.715.0<0.001

35 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.

36 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 anti- biotics, pressors and neupogen she dies 2 days later.

37 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.

38 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

39 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)

40 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.

41 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

42 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).

43 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.

44 Copyright restrictions may apply. Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566. Trends in the US death rate from fatal medication errors and from other causes of death (January 1, 1983-December 31, 2004)

45 Copyright restrictions may apply. Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566. Trends in the US Death Rate From FMEs and From Other Causes of Death, 1983 to 2004

46 Copyright restrictions may apply. Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566. 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)

47 Copyright restrictions may apply. Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566. Trends in the US FME Death Rate by Type of Circumstance in Which the FME Occurs and for Various Comparison Groups, 1983 to 2004a

48 Copyright restrictions may apply. Phillips, D. P. et al. Arch Intern Med 2008;168:1561-1566. Increase in US fatal medication error (FME) death rates by age group (A) and various demographic characteristics (B) (January 1, 1983-December 31, 2004)

49 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.

50 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

51 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

52 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

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