Medication review plus person-centred care: a feasibility ...
What a Person Can Do to Help Increase Medication Safety
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www.npjournal.org The Journal for Nurse Practitioners - JNP 705 Over the past few years a lot of attention has been paid to the many medication errors that patients experience. There are different ways of looking at the variables responsible for causing these problems, and there is some overlap in the literature. No matter how the problems are classi- fied, the focus has to be on how to decrease the number of errors. Elder et al 1 reviewed the literature on errors in primary care, classifying errors into those of diag- nosis, treatment, and preventive services. Process errors were clinician, communication, administra- tion, and other miscellaneous causes (eg, regula- tions, funding). Treatment errors were divided into drug and nondrug errors. The drug-related errors were incorrect drug, incorrect dose, delayed administration, and omitted administration. Maguire 2 stated that medication errors are sec- ond in frequency in the outpatient setting only to failure to diagnose. A big problem is monitoring for adverse drug reactions in new medications and in older medications with known risks such as angiotensin-converting enzyme (ACE) inhibitors (hyperkalemia). For prevention of adverse reactions, Maguire suggested drawing up contracts with patients who take drugs for chronic conditions. Organizations are encouraged to establish a track- ing system and offer no automatic refills. Patient education about medications is important. It the patient and family know what should happen, they will be more likely to pick up errors and note adverse effects. Another big problem is in the use of paper pre- scriptions. Many things cay be done to reduce errors when using paper prescriptions, including printing the text rather than using cursive, making an effort to write legibly, note the purpose of the drug on each prescription, keep up-to-date medica- tion and allergy lists for patients in their chart, and pay particular attention to prescriptions when patients are discharged from the hospital. The American College of Physicians has other safety tips and information online. 3 Doherty et al 4 identified a lack of drug knowl- edge as responsible for many prescription errors. This includes indication errors, dosing errors, and drug–drug interactions. Clinicians may lack informa- tion about the patient, which includes inadequate records and undocumented allergies. Communica- tion failures include poor handwriting, misinter- preted verbal orders, and use of abbreviations or misplaced decimals. Clinician–patient communica- tion errors include failure to explain possible adverse effects before treatment is initiated, failure to ask about adverse reactions in follow-up visits, and failure to ask patient about other medications the patient is taking. Other errors are seen particularly in the elderly such as polypharmacy and inappropriate medica- tions, compliance, age-related pharmacokinetic changes, PRESCRIPTION PAD Maren Mayhew WHAT A PERSON CAN DO TO HELP INCREASE MEDICATION SAFETY
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Transcript of What a Person Can Do to Help Increase Medication Safety
www.npjournal.org The Journal for Nurse Practitioners - JNP 705
Over the past few years a lot of attention hasbeen paid to the many medication errors thatpatients experience. There are different ways oflooking at the variables responsible for causingthese problems, and there is some overlap in theliterature. No matter how the problems are classi-fied, the focus has to be on how to decrease thenumber of errors.
Elder et al1 reviewed the literature on errors inprimary care, classifying errors into those of diag-nosis, treatment, and preventive services. Processerrors were clinician, communication, administra-tion, and other miscellaneous causes (eg, regula-tions, funding). Treatment errors were divided intodrug and nondrug errors. The drug-related errorswere incorrect drug, incorrect dose, delayedadministration, and omitted administration.
Maguire2 stated that medication errors are sec-ond in frequency in the outpatient setting only tofailure to diagnose. A big problem is monitoring foradverse drug reactions in new medications and inolder medications with known risks such asangiotensin-converting enzyme (ACE) inhibitors(hyperkalemia). For prevention of adverse reactions,Maguire suggested drawing up contracts withpatients who take drugs for chronic conditions.Organizations are encouraged to establish a track-ing system and offer no automatic refills. Patienteducation about medications is important. It thepatient and family know what should happen,they will be more likely to pick up errors and noteadverse effects.
Another big problem is in the use of paper pre-scriptions. Many things cay be done to reduceerrors when using paper prescriptions, includingprinting the text rather than using cursive, making
an effort to write legibly, note the purpose of thedrug on each prescription, keep up-to-date medica-tion and allergy lists for patients in their chart, andpay particular attention to prescriptions whenpatients are discharged from the hospital. TheAmerican College of Physicians has other safetytips and information online.3
Doherty et al4 identified a lack of drug knowl-edge as responsible for many prescription errors.This includes indication errors, dosing errors, anddrug–drug interactions. Clinicians may lack informa-tion about the patient, which includes inadequate
records and undocumented allergies. Communica-tion failures include poor handwriting, misinter-preted verbal orders, and use of abbreviations ormisplaced decimals. Clinician–patient communica-tion errors include failure to explain possibleadverse effects before treatment is initiated, failureto ask about adverse reactions in follow-up visits,and failure to ask patient about other medicationsthe patient is taking.
Other errors are seen particularly in the elderlysuch as polypharmacy and inappropriate medica-tions, compliance, age-related pharmacokinetic changes,
PRESCRIPTION PAD
Maren Mayhew
WHAT A PERSON CAN DO TO HELP
INCREASE MEDICATION SAFETY
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November/December 2006706 The Journal for Nurse Practitioners - JNP
JNP
and age-related pharmacodynamic changes. Indealing with the elderly it is recommended that cli-nicians use fewer drugs, consider alternatives, startlow and go slow, titrate therapy, educate thepatient about his or her drugs, and review the needfor drugs regularly.5 Lists of specific drugs withincreased risk in the elderly are available.
The researchers all agree that going back to thetime-honored guidelines in avoiding medicationerrors will help improve patient safety. Commonprinciples that have emerged include the following.
The Right Drug
Lack of Drug Knowledge
• Do not rely on memory; check an updatedresource every time you write a new prescription.
• Use something like the NP’s Prescribing Ref-erence (646-638-6062) or Epocrates(www.Epocrates.com) on a PDA.
• Specifically check indications, contraindica-tions, dose, and drug interactions.
• Have a thorough reference available to look upadditional information, such as Mosby’s DrugConsult or Pharmacology for Primary CareProviders.7
• Develop a process to keep up on new druginformation.
• Check the Food and Drug Administrationwebsite (www.fda.gov) regularly for newinformation.
• The Agency for Healthcare Research and Qual-ity (www.ahrq.gov) has the latest informationon evidence-based practice.
Sources of information are limitless. Make sureeverything is updated and reliable.
Lack of Patient Information and Communication
Keeping a good chart is probably the single mostimportant step in the process. This takes moretime initially but saves a lot more time and issafer later.
• When seeing a new patient, ask for oldrecords.
• When getting old records, review and summa-rize any medications tried before and the resultand past diagnoses.
• Keep an updated medication and allergy list.Ensure that your records have medications andallergies prominently listed. Check lists periodi-cally with the patient or the family. Whenrecording allergies, document the specific reac-tion that occurred.
• Inform the patient, family, or both about anynew medication:• Explain the medication carefully to the
patient.• Warn of potential serious or common
effects.• Review risks versus benefits.
• Use the informed consent concept to be surethe patient understands and agrees.
• Consider written contracts for high-risk medica-tions such as those with black box warnings.
Write Prescriptions ThatCannot Be Misinterpreted
• This encompasses good work habits. Writelegibly or use a computer program to writeprescriptions. Review your orders as thoughtrying to misunderstand them to look for possi-ble errors.
• Use accepted abbreviations. See the ISMPwebsite (www.ismp.org) for lists of unaccept-able abbreviations, medications easily con-fused, and so forth.
• When giving a verbal order, have the receivingperson repeat it back to you.
Ensure That MedicationsAre Given Correctly
• This depends on the setting. If the patient is ina facility, ensure that the staff member takesthe order and administers it correctly, keepingaccurate records.
• If the patient lives at home, ensure that he orshe is taking the medication correctly.
• Monitor refills.• Know what the patient is taking:
• Ask what the patient is taking at every visit.• Specifically ask about herbal and over-the-
counter medications.• If the patient does not remember his or her
drugs, have the patient bring in all medica-tions at the next visit.
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Follow-up• Establish a tracking system to ensure follow-
up of that patient. This can be done by com-puter or even just notations on a calendar.Flow sheets may be used, especially for com-mon drugs given frequently, such as warfarin.Tracking systems often require careful cus-tomizing so they are site specific. Perhaps acolumn on the medication list stating whatmonitoring should be done for each medica-tion would help.
• Ensure that the recommended follow-up labo-ratory tests are done in a timely fashion.
• Check for efficacy and adverse effects of themedication.
• When a patient calls or comes in for a refill,check to see that appropriate tests have beendone and screen the patient for potentialadverse reactions.
Decreasing medication errors requires the per-sonal commitment of every health care provider. Wewould be very interested in hearing from readersabout particular things they have instituted that havemade a difference in decreasing errors in patient set-tings. Send your suggestions or comments [email protected].
References
1. Elder NC, Covey SM. Classification of medical errors andpreventable adverse events in primary care: a synthesis of theliterature. J Fam Pract. 2002;51(11):927-932. Available at:www.jfponline.com/pdf%2F5111%2F5111JFP%5FspecialArticle%2Epdf. Accessed July 5, 2006.
2. Maguire P. Strategies to tackle outpatient errors. Am CollPhysicians. 2002. Available at: www.acponline.org/journals/news/jun02/errors.htm. Accessed June 27, 2006.
3. American College of Physicians keeps online safety tips andinformation. Available at: www.acponline.org/ptsafety/index.html.
4. Doherty K, Segal A, McKinney PG. The 10 most commonprescribing errors: tips on avoiding the pitfalls. Consultant.2004;February:175-182.
5. Stratton MA, Gutierres S, Salinas R. Drug therapy in the elderly: tipsfor avoiding adverse effects and interactions. Consultant.2004;March:461-467.
6. Mosby’s Drug Consult, St Louis, Mo: Mosby; 2005.7. Edmunds ME, Mayhew MS. Pharmacology for Primary Care
Providers. 2nd ed. Philadelphia, Penn: Elsevier; 2003.
1555-4155/06/$ see front matter© 2006 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2006.10.010
Maren Mayhew, MS, ANP, GNP, is the author and editorof Pharmacology for Primary Care Providers, a textbookfor NPs published by Mosby. She can be reached [email protected]. This is a monthly columnon medication news and controversies. Suggestions fortopics are welcome.
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