1. TLCTLC TLCTLC LTCLTC LTCLTC Geriatric Education Center of Greater Philadelphia When Wrong Things Happen with Medications: Risk and Prevention – The Role of the Medication Team in Preventing and Managing Problems with Medications by Donna Miller, DO Director, Geriatrics Institute St. Luke’s Hospital & Health Network Bethlehem, 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

2. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Learning Objectives At the end of this module you will be able to: 1.Describe common factors that are associated with ADEs 2. Describe best drug prescribing practices for nursing homes and other long term care settings 3. Describe the core and supportive roles of health care professionals and caregivers in medication management. 4. Describe a quality improvement approach to preventing, recognizing, and managing ADEs.

3. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Adverse Drug Event (ADE) What is an Adverse Drug Event? An adverse drug event is “an injury resulting from the use of a drug”

4. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Adverse Drug Event (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

5. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

6. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

7. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

8. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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)

9. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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)

10. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Medications with High Rates of ADEs Medication; ClassADEPrevention Strategies Anti-coagulants, Warfarin Drug-drug interactions; Bleeding Verify medications and doses; regular blood work InsulinHypoglycemia-related falls Do not use sliding scale “coverage” DigoxinToxicityLimit total daily dose to 0.125 mg Anti-PsychoticsConfusion, altered mental status Ascertain need for medication, monitor response DiureticsElectrolyte imbalanceKeep older adult well- hydrated

11. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Drug Use Among Older Persons 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

12. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

13. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

14. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Common Serious Medication Interactions Among Older Adults Warfarin –NSAIDS –Sulfa –Macrolides –Quinolones –Phenytoin ACE Inhibitors –Potassium supplements –spironolactone Digoxin –Amiodarone –Verapamil Theophylline –Quinolones

15. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Medication Reconciliation in Long-Term Care Verification –Collect medication history Clarification –Check medications, doses, and instructions Reconciliation –Document changes in orders

16. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

17. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC All Team Members Are Alert to the Five Rights Right Patient Right Drug Right Dose Right Time Right Route

18. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

19. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Medication Team: Prescribing Physician, NP, or PA More 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

20. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

21. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

22. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Nursing Assessment Vital Signs –Orthostatic BP and Pulse Mental Status GI system Falls

23. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Documentation Changes in behavior, signs, or symptoms Monitoring efforts and results of assessments Actions taken in relation to findings, and older adult’s response

24. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Medication Team: 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

25. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

26. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

27. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

28. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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

29. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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?

30. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Videotape “When Wrong 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)

31. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC 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?

32. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Leadership and Staff: Lois K. Evans, DNSc, RN, FAAN Series Associate Editor Viola MacInnes Independence Professor School of Nursing University of Pennsylvania Sangeeta Bhojwani Associate Director, Series Assistant Editor DVGEC University of Pennsylvania Kathleen Egan, PhD Series Editor DVGEC Program Administrator Director, DVGEC University of Pennsylvania Mary Ann Forciea, MD Series Associate Editor Clinical Associate Professor of Medicine Division of Geriatric Medicine, University of Pennsylvania

33. © 2012 University of Pennsylvania Geriatric Education Center of Greater Philadelphia TLCTLC TLCTLC LTCLTC LTCLTC Thank you for your attention! The End