Iatrogenesis Flashcards
Definition of Iatrogenesis
Harm caused by medicine or a physician
- Deleterious effects of therapy or diagnostic procedures independent of the condition they were used for
- Can have devastating psychomotor and social consequences
If ranked, Iatrogenesis would rank ____ in the leading cause of death
6th!
Adverse Drug Reaction (ADR)
Noxious response to drugs used in usual doses
Adverse Drug events (ADEs)
Any injury that occurs from a drug
- usually dose-related
- Noxious response
- Drug administration error
- Any other circumstance that leads to an injury
Prevalence of ADRs and ADEs
- 3-7% of all hospital admissions
- 88% preventable
- 100,000 emergency visits from ADEs
- 5-10% of hospital costs
How ADE’s happen in…. nursing homes
- Inappropriate ordering
- Inadequate monitoring
How ADE’s happen… in the community
Patient errors
Any new symptom in the elderly is _________ until excluded
Drug-related
Risk factors for PDE’s
- Polypharmacy
- Multimorbidity
- No safety profile studies
- Multiple physicians
- Altered drug metabolism
- Cognitive impairment
- Functional deficits and disabilities
- Hospitalization for medical or surgical procedures
What percentage of people 57-85 have at least one prescription?
- 81%
On average, how many medications are nursing home residents on?
7-8, with 33% having 9 or more
How many people on medicare have 5 or more medications?
50%
What does polypharmacy and mutimorbidity increase the risk of?
- ADRs
- Drug-drug interactions
- Hip fractures
- “prescribing cascades”
- Non-adherence to medications
What is a prescribing cascade?
- Drug-related symptoms misinterpreted as new illness
- so then that provider adds another medication….
Tools to improve prescribing practices
- Beers criteria
- START/STOPP criteria
- FORTA list
- Medication appropriateness index (MAI)
- ACOVE project
- GerontoNet ADR risk score
- Comprehensive geriatric assessment
Beers criteria
- revised in 2015- originally designed for nursing homes
- List of inappropriate medications for older adults
- Most commonly found inappropriate drug used- NSAIDs
START/STOPP criteria
- Comparable to Beers
- Screening tool of older person’s prescriptions
FORTA List
Fit for the Aged 4 Categories - Clear benefit - Proven but limited efficacy - Questionable efficacy - Clearly avoid
MAI
Instrument for pocket use
- 10 questions to improve dosage, check indication, and adapt medication list
Medicare/Medicaid DUR criteria
Targets 8 drug classes - Digoxin - ACEI - NSAIDs - Antipsycotics - Antidepressants - CCBs - H2RB - BDZs and 4 problems - Inappropriate dosage - Inappropriate duration - Duplication of Rx - Drug-drug interactions
ACOVE Indicators
Assessing Care of Vulnerable Elders
- Document indication for new drug therapy
- Educate patients on benefits and risks associated with use
- Maintain a current medication list
- Document response to therapy
- Periodically review ongoing need for drug therapy
- All vulnerable elders should have annual medication reviews
- Education and monitoring is needed for warfarin therapy
- Check serum creatinine and potassium annually if on ACEI
- Check electrolytes annually if on loop diuretics
GerontoNet ADR Risk Score
will be test question
4 or more comorbidities- 1 pt Congestive Heart Failure- 1 pt Liver disease- 1 pt Renal failure- 1 pt Previous ADR- 2 pt Number of drugs - less than 5- 0 pts - 5-7- 1 pt - more than 8- 4 pts.
0-1 pts- low risk for ADR
2-4 pts- Moderate risk for ADR
5-8 pts- high risk for ADR- needs intervention
9-12 pts- Very high risk for ADR- needs urgent intervention
Strategies
- Review current medication list and maintain accurate list
- Brown bag checkups
- Discontinue unnecessary medication
- Substitute problematic medications with safer ones
- Reduce the dose and simplify dosing schedule and use organizers
- Educate patient of indications and side effects
- Consult community pharmacists
- Consider non-pharm interventions
Proven Interventions (proven to work)
- Facilitate communication among healthcare practitioners
- Reduce language barriers and disabilities
- Use of care managers
- Multidisciplinary approach to hospitalized elderly (ACE units)
- Appropriate prescribing
- Nursing education programs
- Pharmacist consultation
Iatrogenesis in Diagnostic and therpeutic procedures…
- Invasive procedures
- Use of contrast dye
- Radiation
ex. -colonic perforations from colonoscopy
- UTIs from cathetors
- CHF with too much IV fluids
- Pneumothorax from theracentesis
How to prevent Iatrogenesis events in diagnostic and therapeutic procedures
- Determine risk-benefit ratio proactively
- Err on the side of caution when assessing situation
- Timely diagnosis of surfical emergencies and optimal perioperative care
- Ensure patient has clear understanding of risk and benefits
Iatrogenesis- Nosocomial infections
- occurs in 6-17% of hospitalized older adults
- 33% are preventable
- Highest risk are the terminally ill and immunocompromised
- Most common or UTIs and Pneumonia
- Others are MRSA, C. Dif, Candidal infection
How to prevent nosacomial infections
- Hand washing
- Staff/Patient/Family education
- Reminders of infection control
- Active infection surveillance
Iatrogenesis- Delerium
- One of most common iatrogenic complications in hospitals
- High-risk in post-op hip fractures and thoracic surgery
- Increases morbidity, hospital stays and risk for more iatrogenic cascades
Preventing Delerium
- Target risk factors that may trigger episode- frequent room change, invasive procedures, loud noises, poor lighting
- Promote good sleep habits
- Help patient remain calm and well-oriented
Iatrogenesis- Urine Incontinence
- 33% acute care, up to 80% in Nursing homes
- Mostly functional
- Contributes to pressure ulcers, social isolation, and depression
Preventing Urinary incontinence
- Care plans for UI
- Use of absorbent products
- Fixed-interval toileting
- Containment
- Avoid bladder irritants, such as caffeine and acidic foods
- Prevent constipation
Pressure ulcer causes and prevention
Causes
- Malnutrition
- Inactivity
- Dehydration
- Skin changes
Prevention
- Repositioning
- Skin care
- Nutrition
- Exercise
Causes of fecal impaction
- Polypharmacy
- laxative abuse
- Immobility
- Reduced fluid intake
- Malnutrition and weakness
- Depression and dementia
Preventing fecal impaction
- Dulcolax
- Metmucil- bulk fiber laxatives
- Glycerin suppositories- (colace)
- Stool softeners (docusate)
Other causes of Iatrogenesis (misc)
- Malnutrition and dehydration
- Depression
- Falls and other accidents
- Harmful effects related to values, beliefs, prejudices, and attitudes of well intentioned but ignorant providers
