Medication error, ID, Reconciliation

Question 1

Explain 15 %/ >40%/ 60% in terms of scope of drug usage among patients > 65 yrs old

Answer 1

In Canada-15% of population is 65 or older
They represent >40 % Rx drug Sales
60% Public drug program spending

Question 2

5 risk factors for Inappropriate Medication Use

Answer 2

1) #of RX and non RX drugs ( poly pharmacy 5+,9+)
2) # of co-morbidities
3) Prescribers without Training in Geriactrics
4) Higher level of patient care ( nursing home➡️acute hospital➡️primary care)
5) age

Question 3

Which level of patient care have the highest level of risk?

Answer 3

Nursing home

Question 4

True or false? More medications leads to greater risk of being prescribed something inappropriate

Answer 4

True

Question 5

True or false: ANY symptom in an Elderly patient should be considered a drug side effect until proven otherwise

Answer 5

TRUE

Question 6

Name 8 Poor Health Outcomes related to Inappropriate Medication Use:

Answer 6

1) adverse drug reactions or 2) Falls
⬇️
3) hospitalization or ➡️4)health care service utilization
-can lead to 5) mortality - can lead to 6)increased cost or 7) reduced quality of life 8) Medication Non adherence

Question 7

Name 8 Medication Related Problems

Answer 7

1) untreated condition 2) failure to receive medication
3) sub therapeutic dose 4) overdose 5) drug use without indication 6) improper drug selection
7) drug interaction 8)adverse drug event

Question 8

What % of ADE ARE considered Preventable and what is the most considered the most frequently preventable ADE

Answer 8

42%, Medication errors

Question 9

Name 6 medications that are the most frequently associated with PREVENTABLE ADEs

Answer 9

1-warfarin 
2-atypical antipsychotics
3-intermediate acting benzodiazepines 
4-opioids
5- loop diuretics 
6- Ace inhibitors

Question 10

What is the acronym for looking at symptoms of Medicated-Related problems?

Answer 10

CLEAR

Question 11

What does each letter stand for in CLEAR

Answer 11

COGNITIVE changes 
LOSS of bladder of bowel control
EATING or appetite changes 
ACTIVITY or energy changes
RECURRENT falls

Question 12

Name 2 methods to assess Medication Appropiateness

Answer 12

Implicit methods

Explicit methods

Question 13

Name 2 IMPLICIT methods to assess Medication Appropriateness

Answer 13

MAI- Medication appropriateness index

Drug Regimen Review checklist

Question 14

The challenge with using MAI

Answer 14

1) You must know something about the drug to apply it

2) Must use it on each and every medication

Question 15

6 categories for Drug Regimen Review Checklist

Answer 15

• indication
• effectiveness
• safety
• monitoring
• errors
• cost

Question 16

Name 3 Explicit methods to assess Medication Appropriateness

Answer 16

STOPP( screening tools of older people’s potentially Inappropriate prescriptions)
START ( screening tool to alert doctors to RIGHT treatments)
BEERS

Question 17

How many STOPP criteria to identify PIMs (potentially Inappropriate Medication)

Answer 17

80

Question 18

START criteria identify OVERuse or UNDERuse of medication , what 2 other things it can identify and how many criterias are used

Answer 18

UNDERuse , prescribing omissions and under treated conditions
34

Question 19

Where did START AND STOPP criteria originate

Answer 19

Ireland

Question 20

Which 2 tools look at overuse of medication

Answer 20

STOPP and BEERS

Question 21

When did BEERS start and year of most recent version

Answer 21

1991, 2015

Question 22

How many PIM or medication classes do BEERS identify in 2015 update?

Answer 22

40+

Question 23

Name 5 categories of BEERS

Answer 23

• Medications to avoid in older adults
• Medications to avoid in older adults w: Specific Diseases/ Syndromes
• Medications to be USED WITH CAUTION in older adults
• Clinically important drug-drug interactions
• Medications for which DOSAGE ADJUSTMENT is required based on RENAL IMPAIRMENT ( based on expert panel and not package inserts)

Question 24

Name 2 LISTS in BEERS

Answer 24

List of drugs with ANTICHOLINERGIC properties

List of SAFER alternatives and Complete References

Question 25

BEERS change with nitrofurantoin and why?

Answer 25

CrCl CUTOFF for Use changed from <60 ml/min to <30 ml / min

New data suggest relative Safety and Effectiveness at a lower threshold of renal impairment

Question 26

What Caveats with BEERS concerning nitrofurantoin

Answer 26

Still avoid LONG TERM use for suppression of bacteria because of RISK of 1) pulmonary toxicity

               2) hepatotoxicity
               3) peripheral neuropathy

Question 27

What 3 problems can long term use of nitrofurantoin cause regardless of creatinine clearance

Answer 27

Pulmonary toxicity
Hepatotoxicity
Peripheral neuropathy

Question 28

What 2015 BEERS changes(2) regards to NONbenzodiazepine ( ex. Zolpidem )

Answer 28

1-Changed from Avoid chronic use( >90 days) to AVOID USE regardless of duration ; changed from a limit to JUST AVOID
2-added to list of drugs to avoid in patients with DEMENTIA and COGNITIVE IMPAIRMENT

Question 29

Why did BEERS change NONbenzodiazepine use and evidence of harm was seen since which year

Answer 29

• they had MINIMAL impact on sleep LATENCY and DURATION
  -⬆️risk of hip fractures in nursing home residents especially new users
  Harm seen since 2012

Question 30

What BEERS change regarding PPI?

Answer 30

Avoid use for GREATER THAN 8 weeks

Question 31

Proton pump inhibitors can increase risk of what 3 things?

Answer 31

Clostridium difficile infection
Bone loss
Fractures

Question 32

Warning or caveat to BEERS CHANGE with PPI/ when is it appropriate (3)

Answer 32

PPIs appropriate for patients with high risk, compelling indications, or demonstrated need for MAINTENANCE therapy

Question 33

Caveat to BEERS change regarding NONbenzodiazepine.

Answer 33

None due to mounting evidence since 2012

Question 34

2015 BEERS list change regarding Opioids and why?

Answer 34

Opioids was added as a medication to avoid in patients with HX of falls and fractures
Because opioids may cause Ataxia, Impaired psychomotor function and Additional Falls

Question 35

Name 2 caveats to Beers opioid change

Answer 35

• Exclude pain management due to RECENT fracture or joint replacement
• If used, reduction of other CNS-active medications is recommended

Question 36

2015 BEERS change regarding Antipsychotics and why?

Answer 36

Antipsychotics were added to AVOID First-line in patients with DELERIUM
Because antipsychotics have the potential to 1)Induce or Worsen delirium and 2) they are associated with cerebrovascular accident and mortality in patients WITH DEMENTIA.

Question 37

2 caveats to BEERS change regarding antipsychotics

Answer 37

-avoid for patients with Behavioral problems UNLESS non pharmacologic options have failed and patient is a harm to self or others
-AVOID EXCEPT for Schizophrenia
Bipolar disorder
or Short term use as an antiemetic during chemo

Question 38

5 Strategies for Pharmacists

Answer 38

• Utilize AVAILABLE tools
• Employ technology ( clinical decision support system, medstopper.com)
• Involve Patients and Caregivers in decision- making
• Deprescibing strategies
• Consider Multidisciplinary approaches whenever possible

Question 39

Name 3 Drugs that should be priority when deprescribing

Answer 39

• benzodiazepines
• PPI
• sulfonylureas

Question 40

Name 6 steps in Deprescibing Protocol

Answer 40

1- Identify ALL drugs and Reason for taking
2-Consider Risk of drug- induced harm to Determine the required Intensity of DEPRESCRIBING
3-Assess Each drug in regard to Current/ future BENEFIT potential and compare with HARM potential
4-Prioritize drugs to D/C ( shared decision)
5-Implement Tapering/ Withdrawal process and Monitor for Improvement or onset of Adverse effects
6-Document process and outcomes and share with all relevant healthcare professionals

Question 41

What is ADWE and define it

Answer 41

Adverse drug Withdrawal event

A clinical set of Symptoms or Signs that are related to the removal of a drug

Question 42

Name 3 commonly Implicated classes for ADWE and example for each

Answer 42

CNS Medications - benzodiazepines
Cardiovascular- diuretics and Beta blockers
GI Medications- PPI ( rebound hypersecretion , should try to slowly d/c after 3 weeks