K. NG1,3 and C. HO1,2

1. Institute for Safe Medication Practices Canada

2. Leslie Dan Faculty of Pharmacy, University of Toronto

3. School of Pharmacy, University of Waterloo

INTRODUCTION

Potentially inappropriate medication use: use of a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is evidence in favour of a safer or more effective alternative therapy for the same condition.1,4

• Half of the seniors taking five or more medications experienced an adverse effect requiring medical attention.2 This included preventable side effects such as cognitive impairment, and falls which account for a significant portion of emergency room visits and hospitalization.2,3,4

• The Beer’s criteria6, STOPP criteria7, and the anticholinergic burden scale8 have been developed and applied in several different healthcare settings to prevent potentially inappropriate prescribing.

CONCLUSION(S)

RESULT(S)

METHOD(S)

ACKNOWLEDGEMENTS ISMP Canada would like to acknowledge support from the Ontario Ministry of Health and Long-Term Care for the development of the Community Pharmacy Incident Reporting (CPhIR) Program (http://www.cphir.ca). The CPhIR Program also contributes to the Canadian Medication Incident Reporting and Prevention System (CMIRPS) (http://www.ismp-canada.org/cmirps/). A goal of CMIRPS is to analyze medication incident reports and develop recommendations for enhancing medication safety in all healthcare settings. The incidents anonymously reported by community pharmacy practitioners to CPhIR were extremely helpful in the preparation of this multi-incident analysis.

OBJECTIVE(S)

This multi-incident analysis identifies points of intervention in the community setting in order to prevent medication incidents that may compromise patient safety.

REFERENCES 1. Canadian Institute for Health Information. Drug use among seniors on public drug programs in Canada, 2012 [Internet]. Ottawa, ON: 2014 [cited 2015 Mar 31].71p. Available from: https://secure.cihi.ca/free_products/Drug_Use_in_Seniors_on_Public_Drug_Programs_2012_EN_web.pdf 2. Kwan D. Polypharmacy: optimizing medication use in elderly patients. CGS Journal of CME. 2014; 4(1):21-27. Available from: http://www.canadiangeriatrics.ca/default/index.cfm/linkservid/BE34AED2-D5B7-B425-A21527A9E6498A4D/showMeta/0/ 3. Patodia R. The aging population and the impact on pharmacy. TechTalk CE – The National Continuing Education Program for Pharmacy Technicians 2009; April: 1-4. 4. Coronsello A, Onder G, Abbatecola AM, Guffanti EE, Gareri P, Lattanzio F. Explicit criteria for potentially inappropriate medications to reduce the risk of adverse drug reactions in elderly people. Drug Saf. 2012:35(1):21-28. doi:10.1007/BF03319100. 5. Yoo L, Ho C. Enhancing Medscheck, improving outcomes. Pharmacy Connection. [Internet]. 2010 Mar. [cited 2015 Mar 31]. Available from: https://www.ismp-canada.org/download/PharmacyConnection/PC_MarApr2010p7.pdf 6. Ontario Ministry of Health and Long Term Care. The MedsCheck program guidebook [Internet]. ON: Queen’s Printer for Ontario; 2008 [updated 2011 Sept 13; cited 2015 Mar 30]. Available from: http://www.health.gov.on.ca/en/pro/programs/drugs/medscheck/resources.aspx 7. ISMP Canada. Concerned reporting: mix-ups between bisoprolol and bisacodyl. ISMP Can Saf Bull [Internet]. 2012 Aug 30 [cited 2015 Apr 3];12(9):1-6. Available at: http://ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-09-ConcernedReporting-BisoprololandBisacodylMixups.pdf 8. ISMP Canada. Medication safety self-assessment for community/ambulatory pharmacy. Canadian Edition. Toronto: ISMP Canada; 2006. 9. ISMP Canada. Lowering the risk of medication errors: Independent double checks. ISMP Can Saf Bull [Internet]. 2005 Jan [cited 2015 Mar 30];5(1):1-2. Available from: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-01.pdf 10. ISMP Canada. Transdermal fentanyl: a misunderstood dosage form. ISMP Can Saf Bull [Internet]. 2006 Aug 14 [cited 2015 Apr 3];6(5):1-3. Available at: http://ismp-canada.org/download/safetyBulletins/ISMPCSB2006-05Fentanyl.pdf 11. ISMP Canada. Preventable death highlights the need for improved management of known drug interactions. ISMP Can Saf Bull [Internet]. 2014 May [cited 2015 Mar 31];14(5):1-7. Available from: http://ismp-canada.org/download/safetyBulletins/2014/ISMPCSB2014-5_KnownDrugInteractions.pdf 12. National Association of Pharmacy Regulatory Affairs. Pharmacy care plans [Internet]. Ottawa (ON): National Association of Pharmacy Regulatory Affairs; 2006 [cited 2015 April 3]. Available from: http://napra.ca/pages/Practice_Resources/pharmacy_care_plans.aspx?id=2214 13. ISMP Canada. Preventable death highlights the need for improved management of known drug interactions. ISMP Can Saf Bull [Internet]. 2014 May [cited 2015 Mar 31];14(5):1-7. Available from: http://ismp-canada.org/download/safetyBulletins/2014/ISMPCSB2014-5_KnownDrugInteractions.pdf 14. ISMP Canada. Community Pharmacy Incident Reporting (CPhIR) Database. Available from: http://www.cphir.ca Images: Capsule by Alex Tai from thenounproject.com Medical Checklist by David Courey from thenounproject.com

Potentially Inappropriate Medication Use in Older Adults: A Multi-Incident Analysis

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Theme Subtheme Possible Contributing Factors

Patient Specific Factors

Intolerance or Allergies Example) A patient previously taking AccuprilTM 20mg received a new prescription for AccureticTM 20mg/12.5mg. During prescription entry, the pharmacy assistant copied the AccuprilTM over to AccureticTM; however, the patient had a documented sulfa allergy which was missed as a result. Furthermore pharmacist counselling was not done because the patient said "oh yeah, I know all about it”. The patient later that day took a dose of the medication and experienced slight lip swelling which he had to consult a doctor. AccureticTM was immediately discontinued.

Knowledge deficit with

sulfonamide cross-reactivity Lack of communication

between practitioners for documented intolerances and allergies

Assuming the patient knows

“all about it” Look-alike, sound-alike drug

names at order entry lead to the assumption that both medications were the same.

Medical Conditions Example) A doctor wrote a prescription for Zostavax® however the patient had a major contraindication (lymphoma). The injection was stopped immediately before the puncture of the skin.

Lack of knowledge to drug-disease interactions

Outdated records

Inappropriate Dosing Example) A doctor prescribed fentanyl to an opioid naïve patient who was only taking acetaminophen 650mg extended release.

Lack of knowledge or awareness of indications and pharmacokinetics

Drug Interactions

Antibiotics & Chronic Medications Example) A significant interaction between sulfamethoxazole/trimethoprim and Warfarin© was missed at order entry and checking but was discovered only when the patient asked. There was an interaction note at the bottom of the prescription hardcopy but was not seen during checking.

Faulty computer system that does not pick up on drug-drug interactions

Alert fatigue Lack of independent double

checks Incomplete patient profile

during prescribing

Interactions Between Chronic Medications Example) A patient on both Eliquis© and ASA 81mg was prescribed naproxen for 2 weeks. Patient had an incessant nose bleed that ended up requiring hospital treatment. The interaction wasn't relayed to doctor or staff of nursing home to monitor.

Multiple medication use Lack of monitoring and

follow-up Alert fatigue

Drug Duplications

Example) A nursing home patient was on Osto D2 50,000 once daily prior to entering the nursing home. The home recently added Vitamin D 1000 IU daily on top of his existing medications. The patient also takes a daily multivitamin with Vitamin D. He developed Vitamin D toxicity. All vitamin D and calcium was discontinued and adequate hydration was recommended. Physician, pharmacist and nursing staff all missed the multiple sources of vitamin D.”

Lack of communication between healthcare professionals

Lack of knowledge of generic

and brand names

Hierarchy of Effectiveness Categories

Summary of Recommendations

Forcing Functions Setup alert, restrict, or limit certain doses for older adults by programming dispensing software10 (e.g.

dose limits, high alert medications notifications, renally excreted drug reminders)

Restrict copying prescriptions in drug dispensing software5

Automation or Computerization

Ensure system is maintained properly and is updated regularly11

Review severity levels for all drug-drug interaction alerts in pharmacy information systems to balance information needs and to manage “alert fatigue” 11

Implement computer alerts to flag medications within the same class18

Ensure that all medication information available to patients and practitioners includes the generic and brand name (e.g. medication labels, drug information documents, medication profiles) 7,13

Implement computer mnemonics to minimize selection of the wrong medication (i.e. look a-like/sound a-like drug name pairs)7,8

Reminders, Checklists, Double Checks

Perform independent double checks11,9

Arrange for better patient care by scheduling follow-up reminders at time of dispensing10,12

Rules & Policies Education & Information

When a prescription is brought into the pharmacy, verify with the patient or caregiver any clinical information about the patient that is necessary to confirm the appropriateness of the medication and dose (e.g. allergies, opioid tolerance, indication for drug)18

Highlight the importance of look-alike/sound-alike drug names as part of pharmacy staff trainings and internal communication

Educate staff/physicians on medication classes with sulfonamide cross-sensitivities

Offer a comprehensive medication review for patients to carry with them to their doctor appointments6

Educate patients on the importance of retaining an updated medication list5,6

Medical Conditions Example) A doctor wrote a prescription for Zostavax® however the patient had a major contraindication (lymphoma). The injection was stopped immediately before the puncture of the skin.

Lack of knowledge to drug-disease interactions

Outdated records

Intolerance or Allergies Example) A patient previously taking AccuprilTM 20mg received a new prescription for AccureticTM 20mg/12.5mg. During prescription entry, the pharmacy assistant copied the AccuprilTM over to AccureticTM; however, the patient had a documented sulfa allergy which was missed as a result. Furthermore pharmacist counselling was not done because the patient said "oh yeah, I know all about it”. The patient later that day took a dose of the medication and experienced slight lip swelling which he had to consult a doctor. AccureticTM was immediately discontinued.

Knowledge deficit with

sulfonamide cross-reactivity Lack of communication

between practitioners for documented intolerances and allergies

Assuming the patient knows

“all about it” Look-alike, sound-alike drug

names at order entry lead to the assumption that both medications were the same.

Interactions Between Chronic Medications Example) A patient on both Eliquis© and ASA 81mg was prescribed naproxen for 2 weeks. Patient had an incessant nose bleed that ended up requiring hospital treatment. The interaction wasn't relayed to doctor or staff of nursing home to monitor.

Multiple medication use Lack of monitoring and

follow-up Alert fatigue

Patient Specific Factors

Antibiotics & Chronic Medications Example) A significant interaction between sulfamethoxazole/trimethoprim and Warfarin© was missed at order entry and checking but was discovered only when the patient asked. There was an interaction note at the bottom of the prescription hardcopy but was not seen during checking.

Faulty computer system that does not pick up on drug-drug interactions

Alert fatigue Lack of independent double

checks Incomplete patient profile

during prescribing

Drug Interactions

Identified potential contributing factors.

Searched ISMP Canada Community Pharmacy Incident Reporting (CPhIR)14 Database for medication incidents involving drug therapy problems, contraindications, and

duplications in patients over 65 years old from 2010 to 2015.

184 incidents met the inclusion criteria and were included in this multi-incident analysis.

Analyzed and categorized incidents into two themes and further divided into subthemes.

Provided recommendations to fill in patient-safety gaps

Selected Incidents for final analysis.

May 2016 – Copyright © 2016 ISMP Canada. Poster designed by Kevin Li.