medication errors in the clinic february 24, 2009 dave tanaka

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.

DR AUDET: Ms K is a 40-year-old woman who found an errorwith her prescribed medications. She was diagnosed withHIV infection in 1996 and has taken several different drugregimens. Despite the complexity of her drug program, MsK has been able to manage it well. She has taken an activerole in understanding the benefits of her medications andhas not had major adverse effects.Ms K had asked that refills for her prescriptions be calledin to her pharmacy. When the time came to take her newlyfilled prescriptions, she noted that 2 of the drugs were unfamiliarto her, and that 2 of her HIV drugs were missing.

A 40-Year-Old Woman Who Noticed a Medication ErrorDavid W. BatesJAMA. 2001;285(24):3134-3140.

A 40-Year-Old Woman Who Noticed a Medication ErrorDavid W. BatesJAMA. 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 wasconcerned about continuing her planned HIV regimen withoutinterruption. The error was confirmed: Stelazine (trifluoperazine)and ranitidine had been dispensed to herinstead of stavudine and lamivudine.The correct prescriptions were then called in to the pharmacy.Fortunately, Ms K was able to continue her drug regimenuninterrupted and did not experience any harm fromthis event.

What type of error is this?

Transcription 11% Dispensing 14% Prescription 49% Administration 26%

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potentialadverse 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

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 10.6 h/o PUD 12.5 -15.4

Jones, R, Rubin, G, Berenbaum, F, Scheiman, J. ŅGastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugsÓ Am J Med 2008; 121: 464-74.

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

Third Canadian Consensus conference group. J Rheumatol 2006; 33:140-57. First international working party on gastrointestinal and cardiovascular effects of nonsteroidal anti-inflammatory 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.

Rudolph, JL, Salow, MJ, Angelini, MC, McGlinchey, RE. ŅThe anticholinergic risk scale and anticholinergic 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.

Budnitz, D. S. et. al. Ann Intern Med 2007;147:755-765

Potentially Inappropriate Medications for Individuals Age 65 Years or Older

Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults

Daniel S. Budnitz, MD, MPH; Nadine Shehab, 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

Cases National estimate (%)Warfarin 854 17.3Insulin 616 13.0Aspirin 232 5.7Clopidogrel 173 4.7Digoxin 130 3.2Glyburide 98 2.3Acetaminophen-

hydrocodone 76 1.7

Potentially inappropriate medicationsAnticholinergics 38 0.9Nitrofurantoin 25 0.5Propoxyphene 23 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.


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.


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.


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

Proportion per 10,000 Prescriptions Dispensed

Drugs Pre-Intervention Post-Intervention p ValuesMacrolides 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 <0.001Phenytoin cimetidine 5.3 2.6 0.07 fluconazole 13.5 8.6 0.54Theophylline cimetidine 5.8 2.5 0.05 ciprofloxacin 32.7 15.0 <0.001


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 anti-biotics, 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 yearsJAMA 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).


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.

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)



Trends in the US Death Rate From FMEs and From Other Causes of Death, 1983 to 2004



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)



Trends in the US FME Death Rate by Type of Circumstance in Which the FME Occurs and for Various Comparison Groups, 1983 to 2004a



Increase in US fatal medication error (FME) death rates by age group (A) and various demographic characteristics (B) (January 1, 1983-December 31, 2004)


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.


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

medication errors in the clinic february 24, 2009 dave tanaka

Documents

action slide

medication error david

error of commission

type of error

dave tanaka slide

drug program

potential adverse drug

definitions error failure