Medication error, ID, Reconciliation Flashcards
Explain 15 %/ >40%/ 60% in terms of scope of drug usage among patients > 65 yrs old
In Canada-15% of population is 65 or older
They represent >40 % Rx drug Sales
60% Public drug program spending
5 risk factors for Inappropriate Medication Use
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
Which level of patient care have the highest level of risk?
Nursing home
True or false? More medications leads to greater risk of being prescribed something inappropriate
True
True or false: ANY symptom in an Elderly patient should be considered a drug side effect until proven otherwise
TRUE
Name 8 Poor Health Outcomes related to Inappropriate Medication Use:
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
Name 8 Medication Related Problems
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
What % of ADE ARE considered Preventable and what is the most considered the most frequently preventable ADE
42%, Medication errors
Name 6 medications that are the most frequently associated with PREVENTABLE ADEs
1-warfarin 2-atypical antipsychotics 3-intermediate acting benzodiazepines 4-opioids 5- loop diuretics 6- Ace inhibitors
What is the acronym for looking at symptoms of Medicated-Related problems?
CLEAR
What does each letter stand for in CLEAR
COGNITIVE changes LOSS of bladder of bowel control EATING or appetite changes ACTIVITY or energy changes RECURRENT falls
Name 2 methods to assess Medication Appropiateness
Implicit methods
Explicit methods
Name 2 IMPLICIT methods to assess Medication Appropriateness
MAI- Medication appropriateness index
Drug Regimen Review checklist
The challenge with using MAI
1) You must know something about the drug to apply it
2) Must use it on each and every medication
6 categories for Drug Regimen Review Checklist
- indication
- effectiveness
- safety
- monitoring
- errors
- cost
Name 3 Explicit methods to assess Medication Appropriateness
STOPP( screening tools of older people’s potentially Inappropriate prescriptions)
START ( screening tool to alert doctors to RIGHT treatments)
BEERS
How many STOPP criteria to identify PIMs (potentially Inappropriate Medication)
80
START criteria identify OVERuse or UNDERuse of medication , what 2 other things it can identify and how many criterias are used
UNDERuse , prescribing omissions and under treated conditions
34
Where did START AND STOPP criteria originate
Ireland
Which 2 tools look at overuse of medication
STOPP and BEERS
When did BEERS start and year of most recent version
1991, 2015
How many PIM or medication classes do BEERS identify in 2015 update?
40+
Name 5 categories of BEERS
- 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)
Name 2 LISTS in BEERS
List of drugs with ANTICHOLINERGIC properties
List of SAFER alternatives and Complete References
BEERS change with nitrofurantoin and why?
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
What Caveats with BEERS concerning nitrofurantoin
Still avoid LONG TERM use for suppression of bacteria because of RISK of 1) pulmonary toxicity
2) hepatotoxicity
3) peripheral neuropathy
What 3 problems can long term use of nitrofurantoin cause regardless of creatinine clearance
Pulmonary toxicity
Hepatotoxicity
Peripheral neuropathy
What 2015 BEERS changes(2) regards to NONbenzodiazepine ( ex. Zolpidem )
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
Why did BEERS change NONbenzodiazepine use and evidence of harm was seen since which year
- they had MINIMAL impact on sleep LATENCY and DURATION
-⬆️risk of hip fractures in nursing home residents especially new users
Harm seen since 2012
What BEERS change regarding PPI?
Avoid use for GREATER THAN 8 weeks
Proton pump inhibitors can increase risk of what 3 things?
Clostridium difficile infection
Bone loss
Fractures
Warning or caveat to BEERS CHANGE with PPI/ when is it appropriate (3)
PPIs appropriate for patients with high risk, compelling indications, or demonstrated need for MAINTENANCE therapy
Caveat to BEERS change regarding NONbenzodiazepine.
None due to mounting evidence since 2012
2015 BEERS list change regarding Opioids and why?
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
Name 2 caveats to Beers opioid change
- Exclude pain management due to RECENT fracture or joint replacement
- If used, reduction of other CNS-active medications is recommended
2015 BEERS change regarding Antipsychotics and why?
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.
2 caveats to BEERS change regarding antipsychotics
-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
5 Strategies for Pharmacists
- 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
Name 3 Drugs that should be priority when deprescribing
- benzodiazepines
- PPI
- sulfonylureas
Name 6 steps in Deprescibing Protocol
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
What is ADWE and define it
Adverse drug Withdrawal event
A clinical set of Symptoms or Signs that are related to the removal of a drug
Name 3 commonly Implicated classes for ADWE and example for each
CNS Medications - benzodiazepines
Cardiovascular- diuretics and Beta blockers
GI Medications- PPI ( rebound hypersecretion , should try to slowly d/c after 3 weeks
