Download Medications Module: Instructor`s PowerPoint Slides with Notes

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When Wrong Things
Happen with Medications:
Risk and Prevention –
The Role of the Medication Team in Preventing and
Managing Problems with Medications
by
Donna Miller, DO
Director, Geriatrics Institute
St. Luke’s Hospital & Health Network
Bethlehem, PA
Reviewed and updated, Fall 2006 Reviewers: Johanne Louis-Taylor,
MSN, CRNP and GEC Series Editors
Reviewed and updated, Spring 2012 Reviewers: Donna M.Lisi, PharmD,
BCPS, BCPP and Tamara Zurakowski, PhD, GNP-BC
Geriatric Education Center of Greater Philadelphia
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Learning Objectives
At the end of this module you will be able to:
1. Describe common factors that are associated
with ADEs
2. Describe best drug prescribing practices for
nursing homes and other long term care
settings
3. Describe the core and supportive roles of
health care professionals and caregivers in
medication management.
4. Describe a quality improvement approach
to preventing, recognizing, and managing ADEs.
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Adverse Drug Event
(ADE)
What is an Adverse Drug
Event?
An adverse drug event is
“an injury resulting from the
use of a drug”
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Adverse Drug Event (ADE)
Why pay attention to ADEs?
Many people suffer injuries and even
death from ADEs each year
• About one-half of ADEs are
preventable, especially the more
serious ones
• Nursing Homes have high rates of
ADEs: nearly 2 million each year in
the U.S.
• Older adults in community settings:
2/3 make errors with their
medications
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Most Common and Preventable
ADEs in Community Settings
• Altered Kidney Function (e.g.
abnormal levels of waste products,
dehydration)
• Changes in GI Tract (abdominal
pain, diarrhea, constipation)
• Bleeding
• High or low blood glucose
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Most Common and
Preventable ADEs in
Nursing Homes
• Altered Kidney Function (e.g. abnormal
levels of waste products, dehydration)
• Changes in GI Tract (abdominal pain,
diarrhea, constipation)
• Bleeding
• High or low blood glucose
• Mental status changed (confusion,
oversedation, delirium)
– Particularly related to use of psychotropic
medications
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Factors Related to High Rates of
ADEs in Community Settings
• Polypharmacy
• Complex medication
instructions
• New and unfamiliar
medications because of recent
change in medical status
• Unclear discharge informationto continue or not to continue a
prior medication
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Factors Related to High Rates
of ADEs in Nursing Homes
• Prescribing (wrong dose, wrong
drug)
• Transcription (transferring orders
manually onto med sheet)
• Dispensing (from pharmacy to
facility)
• Drug administration (actual delivery
to patient)
• Monitoring (not recognizing signs of
unexpected drug response)
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Which Older Persons Are
Most At Risk for ADE’s?
• Persons taking more
medications
• Persons taking drugs from
several categories
• Persons taking specific
classes of medications (on
next slide)
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Geriatric Education Center of Greater Philadelphia
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Medications with High Rates of
ADEs
Medication; Class
ADE
Prevention Strategies
Anti-coagulants,
Warfarin
Drug-drug
interactions; Bleeding
Verify medications
and doses; regular
blood work
Insulin
Hypoglycemia-related Do not use sliding
falls
scale “coverage”
Digoxin
Toxicity
Limit total daily dose
to 0.125 mg
Anti-Psychotics
Confusion, altered
mental status
Ascertain need for
medication, monitor
response
Diuretics
Electrolyte imbalance
Keep older adult wellhydrated
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Drug Use Among Older
Persons
In the community
In nursing homes
Average 8 drugs per
older adult
Average 8 scheduled
drugs per resident
Includes both
prescription and
over the counter
medications
Additional 3 PRN
medications per
resident
40% of all residents use
≥ 9 medications
One-half (50%) are
“prn” drugs
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Geriatric Education Center of Greater Philadelphia
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Why So Many Meds?
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•
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© 2012 University of Pennsylvania
Older persons have
multiple chronic
medical conditions
Pressure to prescribe
Fragmented assessment
and care
Treating the symptoms
rather than the
underlying problem
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Potentially Inappropriate
Medications In Older Adults
• The Beers Criteria – American
Geriatrics Society, 2012
– Medications that have a high risk of side
effects or limited therapeutic effects in
older adults
– Medications that may exacerbate existing
diseases or conditions
– Medications that may be the best choice
for the older adult, but have associated
risks
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Common Serious Medication
Interactions Among Older Adults
• Warfarin
–
–
–
–
–
NSAIDS
Sulfa
Macrolides
Quinolones
Phenytoin
• Digoxin
– Amiodarone
– Verapamil
• Theophylline
– Quinolones
• ACE Inhibitors
– Potassium supplements
– spironolactone
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Medication Reconciliation
in Long-Term Care
• Verification
– Collect medication history
• Clarification
– Check medications, doses, and
instructions
• Reconciliation
– Document changes in orders
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Who’s on the Medication
Team?
• Prescriber (Physician,
NP, or PA)
• Nurse
• Pharmacist
• Direct Care Staff
(CNA, personal care
aide, etc.)
• Patient/Resident
© 2012 University of Pennsylvania
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•
•
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Family
Dietitian
Social Worker
Physical Therapist
Occupational
Therapist
• Activities
Therapists
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All Team Members Are
Alert to the Five Rights
•
•
•
•
•
© 2012 University of Pennsylvania
Right Patient
Right Drug
Right Dose
Right Time
Right Route
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Medication Team: Prescribing
Physician, NP, or PA
Use best prescribing practices
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•
•
•
Select the best drug or combination for
condition
Start low, go slow, but go!
Avoid drug-drug interactions
Avoid potential drug-disease
interactions
Monitor drugs and patient reaction as
needed
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Medication Team:
Prescribing Physician, NP, or PA
More Best Practices in the Long-Term
Care setting:
• Verify the need for each drug
• Record reason for each drug
• Record results of drug monitoring
• The Consulting Pharmacists are your
best friends
• Be aware of federal and state
regulations regarding prescribing
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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The Well-Written Medication
Order
• Written for a limited number
of days
• Includes daily frequency, not
by specific hours
• Specifies indication for PRN
orders
• Consideration of cost one
factor in selecting medications
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
Medication Team:
Nurse
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Administer medications
Inform CNAs of drug changes and
possible side effects
Encourage CNA reporting
Educate patients about medications
and how to report problems
Use best nursing practices
Assess the older adult
Safeguard against potential errors
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Nursing Assessment
• Vital Signs
– Orthostatic BP and Pulse
• Mental Status
• GI system
• Falls
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Geriatric Education Center of Greater Philadelphia
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Documentation
• Changes in behavior,
signs, or symptoms
• Monitoring efforts and
results of assessments
• Actions taken in relation
to findings, and older
adult’s response
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
Medication Team:
Direct Care Staff
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Observe patients for reactions to
medication changes
Report changes in patients to
nurses
Provide direct care following best
practice guidelines
Work in your team to solve
medication problems
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Observations by the CNA
• Changes in appetite and intake
• Changes in behavior
• Changes in bowel and bladder
patterns
• Changes in functional status
• Changes in skin
• Changes in sleep patterns
• Changes in thinking or memory
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
Medication Team:
Pharmacist
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Perform periodic drug review
Safeguard against potential errors
Work as a member of the team
Educate team members
Recommend medication documentation
standards
Recommend emergency medication
supplies
Replace emergency medications as needed
Recommend appropriate reference
materials
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Medication Team:
Patients and Families
• Communicate new complaints to
caregivers and health care team
• Learn about their current and
new medications
• Check medicines each time they
are taken
• Report any new behaviors or
problems when medications are
taken
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Medication Team and QI
• In any setting with a QI
process, be involved in
monitoring and problem
solving
• Refer medication problems to
QI team
• Involve all medication team
members in identifying root
causes of problems
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Videotape “When Wrong
Things Happen…”
The first segment of this video contains
two scenes. Please watch the segment
with these questions in mind:
• Do you see examples of good nursing
practice?
• Do you see circumstances that could
lead to adverse drug events?
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Videotape “When Wrong
Things Happen…”
The second segment of this video shows a
QI team meeting about the medication
event involving Mrs. Saeger.
How does each of the team members
contribute to solving the problem?
•
•
•
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Administrator
Consulting pharmacist
Nurse
Direct Care Staff (CNA)
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Learning Objectives:
Did we meet them?
Are you now able to:
1. Describe common causes of adverse
drug events?
2. Describe best drug prescribing practices?
3. Describe roles of 4 health care professionals
and caregivers in medication management?
4. Describe a quality improvement approach
to preventing adverse drug events?
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
Leadership and Staff:
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Kathleen Egan, PhD
Series Editor
DVGEC Program
Administrator
Director, DVGEC University
of Pennsylvania
Lois K. Evans, DNSc, RN, FAAN
Series Associate Editor
Viola MacInnes Independence
Professor
School of Nursing
University of Pennsylvania
Mary Ann Forciea, MD
Series Associate Editor
Clinical Associate Professor
of Medicine
Division of Geriatric
Medicine, University of
Pennsylvania
Sangeeta Bhojwani
Associate Director,
Series Assistant Editor
DVGEC
University of Pennsylvania
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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The End
Thank you for
your attention!
© 2012 University of Pennsylvania
Geriatric Education Center of Greater Philadelphia