Download SCI2003 Template - American Pharmacists Association

The Patient’s Role
in Preventing
Medication Errors
Learning Objectives
• Discuss the patient’s role in preventing
medication errors
• List ways in which health care professionals
can assist patients in taking an active role
in their medication therapy plan
Public Awareness of
Medication Errors
• 1997 National Patient Safety Foundation survey:
Public Opinion of Patient Safety Issues
– Respondents believed carelessness and negligence
were the most frequent causes of errors
• The Institute of Medicine (IOM) reports brought
public awareness of medication errors to a new
level
– To Err Is Human (2000)
– Crossing the Quality Chasm (2001)
2004 Patient Awareness Study
• 34% of respondents or a family member had been involved in
a preventable medication error
• 52% and 36% believed the most important cause of errors
were mistakes by individual practitioners and institutions,
respectively
• The lowest-ranked solution for preventing medication errors
was medical malpractice law suits
• 70% believed medication error reports would provide valuable
information they could use to compare hospitals
• Among patients taking precautions to reduce the risk of errors:
• 69% reported checking the medication dispensed against the
physician’s prescription
• 48% reported carrying a list of their medications with them
Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard
School of Public Health. National survey on consumer’s experiences with patient
safety and quality information. November 2004.
Health Care Providers Engaging
Patients as Equal Partners
• To engage patients and families in their health care:
– Make safety a top priority
– Connect with patients on a personal level
• Listen to how medical stories and personal stories interact
– Include patients as an equal member in their own health
care team by encouraging active participation in their care
and in the decision-making process
– Earn patients’ respect by treating them with dignity and
paying attention to the whole patient
– Strive to give patients what they want by actually asking
them what they want
Health Care Providers Engaging
Patients as Equal Partners
• To engage patients and families in their health care:
– Improve adherence to a jointly developed plan of care by
providing good instructions
• Even the most complex processes must be clear and easy
to follow
– Disclose errors — this may require changing the culture
• Patients will not listen to us unless we begin to tell them
what we are doing about the problem of medication errors
– Offer emotional, physical, spiritual, and psychological
support in the wake of a serious error
– Improve the efficiency and safety of our systems
• Free our workforce to talk to patients and their families
Health Care Providers Engaging
Patients as Equal Partners
• To engage patients and families in their health care:
– Disclose all errors accompanied by:
• A fair offer of compensation for injuries through
thoughtfully considering the financial burden placed on
the victims of an error and sharing in that burden up front
– Motivate all patients to engage in their own health care
and safety by providing them with the knowledge to
fully participate
• Provide encouragement from programs such as the Speak Up:
Help Prevent Errors in Your Care campaign from The Joint
Commission
What Is the Patient’s Role?
Patients must know:
• The questions to ask the health care provider
• How to insist on answers
• How to recognize situations that could produce
medication errors
Basic Questions
Patients Need Answered
1. What are the brand and generic names of the
medication?
2. What is the purpose of the medication?
3. What is the strength and dosage?
4. What are the possible adverse effects? What should I
do if they occur?
5. Is there any other medication I should avoid while
using this product?
6. I am allergic to _____. Should I take this medication?
7. How long should I take this medication? What
outcome should I expect?
Basic Questions
Patients Need Answered (continued)
8.
9.
10.
11.
12.
When is the best time to take the medication?
How should I store the medication?
What do I do if I miss a dose?
Should I avoid any foods while taking this medication?
I’m also taking ____ (which I got at another pharmacy).
Can I take both safely?
13. Is this medication meant to replace any other drug that
I am already taking?
14. May I have written information about this drug?
The Answers Should…
• Allow patients to take responsibility for safe drug use
• Be provided at the time the medication is prescribed
— whether in a hospital or in the physician’s office —
to be the most effective
• Provide a basis of information to build upon
– Patients should have an information resource available, such
as a medication handbook or access to the Internet
• Be presented in a format and at a level that the patient
can understand, and be reinforced periodically
• Encourage patients to question anything they do not
understand or is not in keeping with their
understanding
Five Steps to Follow When
Picking Up a Prescription
1.
Take the medicine out of the bag and read the label
•
2.
Are your name and your doctor’s name correct?
Read the directions on the label
•
3.
Make sure that it is what your doctor told you, and that you
understand how much medicine to take and how many
times a day you should take it
While you are still in the pharmacy, read the drug
information sheet stapled to the bag to learn what
the medicine is supposed to treat
•
Is that what you are being treated for?
Five Steps to Follow When
Picking Up a Prescription (continued)
4. Read about the possible side effects
• If you are picking up a refill and realize you have been
having these side effects, tell the pharmacist immediately;
the pharmacist may want to call your doctor
5. If you are getting a refill, make sure the medicine
looks the same as it did last time; if it looks different,
ask the pharmacist about it
• Most likely, the pharmacist has filled your prescription with a
generic drug that looks different from what you are used to
taking
Providing Instructions to
Patients
• Do not assume patients understand
directions
• Give clear and complete instructions, even
about the routine parts of proper medication
use
– Example: A patient interpreted the label on a
coal tar preparation, “take four capfuls in bath”
and proceeded to sit in the tub and swallow the
coal tar solution meant for dilution in the bath
water
Providing Instructions to
Patients
The American Medical Association recommends
six steps for improving communication with
patients:
1. Slow down — speak slowly and spend a small amount
of extra time with each patient
2. Use plain, nonmedical language
3. Show or draw pictures
4. Limit the amount of information provided, and repeat it
5. Use the teach-back or show-me technique
6. Create a shame-free environment
Patient Record Keeping
• Patients should keep updated records of all the medications
and nonprescription products they are taking
• Information to be included in the records:
– Name, strength, dose, and frequency of dosage of all
prescription medications
– Names of all nonprescription medicines, vitamins, and herbal
products
• Herbals may affect the body and cause drug interactions
– Known allergies (medication or food)
– Special diets
– Medications that the patient previously took and the reason
why the medication was discontinued
Patient Record Keeping
• Update medication list whenever medication
regimen is changed
• Medication record-keeping forms are available
from:
– South Carolina Hospital Association
• Multilingual versions are available as well
– Institute for Safe Medication Practices
• http://www.ismp.org/Newsletters/consumer/consumerAlerts.asp
Medication Packaging
• Manufacturers may package their products in
containers that are virtually identical
• Packaging and labeling may mislead users of a product
about the correct doses to take
– Figure 13-2 in the textbook provides an example of ambiguous
packaging
• Dissimilar products can have similar packaging
– Figure 13-3 in the textbook illustrates the similarity of eye
washes and respiratory therapy medications
• Mix-ups have occurred with products in containers
resembling the containers often used for eye drops
– Hemoccult solutions and other testing reagents often resemble
eye drops and have been instilled in the eye
Additional Information on
Look-Alike, Sound-Alike
Medications and Packaging
Available in Slide Deck for
Chapter 6
Error Potential With
Brand Names and Extensions
• Not knowing the generic name could result in a patient taking
both the brand and the generic doses of the same drug
• Different brand names may be used for the same drug when it
is used to treat a different condition
– Prozac for depression, Sarafem for premenstrual dysphoric
disorder
• There are no standard definitions of suffixes such as XL, SR,
and ER
• Brand extensions allow manufacturers to keep a recognized
brand name, but change the active ingredients
– Figure 13-5 in the textbook illustrates two Dulcolax products,
one with bisacodyl as the active ingredient, one with docusate
Brand Names and Extensions
• The pharmacists’ and clinicians’ role:
– Teach patients that each medication has one generic name
but may have one or more brand names
– Provide patients both the generic and the brand name (if
applicable)
– Emphasize the risk of duplicate therapy if the medication
prescribed is also marketed under other brand names
– Provide patients with written instructions about which drug
previously taken at home is being replaced by a newly
prescribed drug
– Encourage patients to properly dispose of discontinued
medications
– Encourage patients to choose single-ingredient products
Readability of Labels
• Most medication packages have limited space for
label information
• In 2002, the use of a new Drug Facts label format
was required for almost all nonprescription
products
– Figure 13-6 in the textbook illustrates the information
and order of presentation on the label
– The language is simple and the type size is larger
• Problems may arise with information put on a
peel-away portion of the label, which might be
overlooked or torn off
Readability of Prescribers’
Handwriting
• Patients should be able to clearly read all
information on their prescriptions before leaving a
physician’s office or hospital
• Patients should ask the prescriber to print or type
drug names instead of writing in cursive
• Prescribers should indicate the purpose of the
drug on the prescription
• This reduces the likelihood of pharmacist
misinterpretation of “look-alike” drug names
Spoken or Phone Orders
to Pharmacists
• The prescriber giving a spoken order to a pharmacist or
nurse should be asked to spell the name of the drug
• The pharmacist or nurse taking the spoken order should
write down the order and read it back to the caller
• Stating the purpose of the medication provides an
additional safeguard
• Advise patients of the risks of spoken orders and ask
them to minimize their requests for telephone
prescriptions
• Faxed or electronic order entry and processing are
preferable to telephone orders
Spoken Orders to Patients
• Patients are often instructed by telephone about
changes in their medication regimens
• The directions on the prescription bottle may
differ from the actual administration directions
• To reduce the risk of error, provide both:
– The patient’s total dose in metric units
– A description of the number of tablets needed for each
dose
Spoken Orders to Patients
• When patients are given orders by telephone,
they should be asked to:
– Retrieve a pen and paper to write any dosage
changes
– Write the information as received and the date
– Read back the dose and instructions to verify
understanding
• Advise patients to keep the dated instructions
with the prescription bottle for quick reference
Spoken Orders: Misidentification
• Errors occur when patients are misidentified
• The possibility of error can be reduced if:
– Patients insist on counseling before leaving the
pharmacy
– Patients check to see that their name is on the label
– Patients check to see that the name of the drug on
the label is the same as the drug name prescribed
by the physician
• The patient’s address or date of birth may be
incorporated into the method of identification
Medication Storage
• Medications should be kept on a kitchen shelf or in a
linen closet — not in the bathroom
– Moisture or heat and humidity may alter the effectiveness of
some medications
– Medications may be confused for other common items
• Keep medications out of reach of children and pets
• Do not leave medications in an automobile
– Extreme temperature variations may alter medications
• Care should be taken when using tablet organizers to
avoid mix-ups between look-alike tablets
• Medications should not be stored in old medication
bottles
– Discard old prescription vials and never store multiple drugs in
the same container
Patient Nonadherence to
Drug Therapy
• Nonadherence can be defined as any one of the
following:
–
–
–
–
–
–
–
–
Not filling a prescription initially
Not having a prescription refilled
Omitting doses
Taking the wrong dose
Stopping a medication without the physician’s advice
Taking a medication incorrectly
Taking a medication at the wrong time
Taking someone else’s medication
Consequences of Nonadherence
• Studies have found up to 93% of patients reporting
some form of nonadherence to medications 1,2
• Nonadherent patients are more likely to be
hospitalized and require more clinic visits than
adherent patients 3,4
• Nonadherence accounts for 10% of hospital admissions
– 25% of hospital admissions among elderly patients
• Cost of nonadherence estimated to be $100 billion to
$300 billion annually
1. Berg JS, et al. Ann Pharmacother. 1993;27:S5–S19.
2. Greenberg RN. Clin Ther. 1984;6:592–8.
3. National Pharmaceutical Council. Noncompliance With Medications: An Economic
Tragedy With Important Implications for Health Care Reform. 1992.
4. McGhan WF, et al. US Pharm. 2001;Impact suppl:1–13.
Consequences of Nonadherence
• A relationship exists between adherence and
how important and desirable the outcome of
treatment appears to the patient
• A patient is more likely to be nonadherent if he
or she:
–
–
–
–
Takes more than one drug
Has a chronic condition
Takes a drug more than once a day
Has a condition that produces no overt symptoms or
physical impairment
Unintentional Nonadherence
• A patient may not intend to be nonadherent
• Reasons for unintentional nonadherence:
– Patient suffers a visual impairment
– Patient does not understand the instructions for
taking the medication
• Language barriers
• Patient may not be literate
Reasons for Nonadherence:
Knowledge Deficits
• Patient may lack knowledge about his or her medication
and condition
• Language barriers may contribute to knowledge deficits
• Health care providers can help overcome this by:
– Providing more information to the patient
– Presenting information in formats the patient can understand
– Having information professionally translated into the most
commonly spoken languages
– Dispelling myths about treatment and disease
– Tailoring the information to the patient’s level of understanding
– Taking into consideration the patient’s cultural and ethnic
background to tailor the presentation
Indicators of Limited Literacy
• Health care providers need to be aware that:
– Knowledge deficits may not always be discernible
– According to a 1993 National Adult Literacy Survey, nearly half
the U.S. population is marginally or functionally illiterate
– Many people function well and have jobs even with low literacy
– Many people hide their illiteracy, even from family
– Some people with limited literacy rely on memory and color,
shape, or other cues instead of words
– Some recent immigrants may use English as a second language
– Some U.S.-born citizens use English as a second language
• See Table 13-1 in the textbook for indicators of limited
literacy
National Center for Education Statistics. Executive summary of adult literacy in
America: a first look at the results of the national adult literacy survey. August 1993.
Reasons for Nonadherence:
Practical Barriers
• Practical barriers for nonadherence include:
–
–
–
–
–
–
Visual impairment
Inability to pay or lack of insurance coverage
Adverse drug reactions
Confusing dosing schedules
Difficult to open containers
Cognitive impairment
Reasons for Nonadherence:
Attitudinal Barriers
• Patient’s health care belief system formed by:
–
–
–
–
–
Culture
Ethnicity
Family
Personal values
Previous experience with the health care system
• Denial of their condition
• Frustration with treatment
• Lack of trust for the health care establishment
Patient Populations Requiring
Special Consideration
• Hospitalized patients
• Elderly patients
• Pediatric patients
Hospitalized Patients
• Hospitalized patients are dependent on hospital
personnel for safe drug use
• Patients are reluctant to ask questions for fear of
being “troublesome”
• Patients need to take an active role
– They should take their medication records and
medicines with them to the hospital, have them
checked by a nurse or doctor, and then send them
home with a family member
• Patients should ensure the nurse has read his or
her armband before giving the medication
Hospitalized Patients
• Patients or a family member needs to ask the
name and purpose of prescribed medication
• Before or at the time of discharge:
– Take the opportunity to talk with a health care provider
about new prescriptions or changes to medications
– Patients’ medication lists should be created or updated
– Follow The Joint Commission medication reconciliation
process:
• Complete medication list upon admission
• Compare with medications subsequently prescribed
• Upon transfer of care, communicate the medication list
to the next provider of service
Elderly Patients
• Practitioners should be aware of the Beers criteria
– Beers criteria: identification of medications to avoid or use with
caution in patients ≥65 years old
• Patient counseling should be done in a sensitive manner
and with a family member or friend if possible
• A medication schedule for the patient is helpful; updates
are essential for each medication change
– Figure 13-8 in the textbook shows an example of a medication
schedule
• Use caution with pill organizers
– Patients should be able to identify medications in case of spills
or changes to their prescriptions
Beers criteria in: Fick DM, et al. Arch Intern Med. 2003:163;2716–24.
Elderly Patients
• Keep medications in original containers
• Ask questions at the time of prescribing;
prescribers may not be aware of a change in
the dosage prescribed earlier
• Inquire about a dosage form of the medication
that is easier to swallow if the patient is having
difficulty
• Patients should check with a pharmacist before
crushing or splitting a dosage form
Pediatric Patients
• Children may be reluctant to take medications
because they do not know the difference between
drugs that help and drugs that hurt
• Children with chronic illnesses may feel hopeless
and become noncompliant
• Children have control over compliance with drug
therapy in a world where they lack control over
many other things
• Child-resistant packaging is necessary to reduce
the risk of accidental poisoning in children
Pediatric Patients
• Adults should:
– Safely store medications, with fastened caps, on a high shelf,
or in a locked box
– Never take their own medications while a child is watching
• The number for poison control should be posted near
the telephone and pointed out to caregivers
– Contact the Universal Poison Control number 1-800-222-1222
before attempting any home remedy
– Neither syrup of ipecac nor activated charcoal is
recommended by the American Academy of Pediatrics for
treating overdoses
Pediatric Patients
• Parents or caregivers should:
– Mark the level of liquid medication after each use to
determine how much a child has accidentally ingested
– When visiting another home, ask the host whether the
medications are stored in a place not accessible to
children
– Caregivers should communicate with each other
about when a child’s next dose is due
• Unit-dose packaging of oral solids makes it more
difficult for children to accidentally ingest drugs
Resources for Patients
• ISMP Consumer Brochure
– Available in the Appendix to Chapter 13 in the textbook
– Provides:
• List of pertinent questions
• Information about precautions patients can take at home
• Information about what patients can do in the hospital
and the physician’s office
• Persons United Limiting Sub-standards and
Errors in Healthcare (PULSE)
– www.pulseamerica.org
• Consumers Advancing Patient Safety (CAPS)
– www.patientsafety.org
References
Berg JS, Dischler J, Wagner DJ, et al. Medication compliance: a
health care problem. Ann Pharmacother. 1993;27:S5–S19.
Fick DM, Cooper JW, Wade WE, et al. Updating the Beers
criteria for potentially inappropriate medication use in older
adults: results of a US consensus panel of experts. Arch
Intern Med. 2003;163:2716–24.
Greenberg RN. Overview of patient compliance with medication
dosing: a literature review. Clin Ther. 1984;6:592–8.
Kaiser Family Foundation; Agency for Healthcare Research and
Quality; Harvard School of Public Health. National survey on
consumers’ experiences with patient safety and quality
information. November 2004. Available at: http://www.kff.org/
kaiserpolls/pomr111704pkg.cfm.
References
Kirsch IS, Jungeblut A, Jenkins L, et al. Executive summary of
adult literacy in America: a first look at the results of the
national adult literacy survey. National Center for Education
Statistics, U.S. Department of Education; August 1993.
Louis Harris and Associates. Public Opinion of Patient Safety
Issues: Research Findings. Prepared for National Safety
Foundation at the AMA. September 1997. Available at:
http://www.npsf.org/download/1997survey.pdf.
McGhan WF, Peterson AM. Pharmacoeconomic impact of
noncompliance. US Pharm. 2001;Impact suppl:1–13.
Task Force for Compliance. Noncompliance With Medications:
An economic tragedy With Important Implications for Health
Care Reform. Washington, DC: National Pharmaceutical
Council;1992:1–16.