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Medication Errors and Reconciliation

Dina J. Costa, ABG; Matthew T. Falvey, TTP; Ryan P.A. Flynn, WNL

Introduction

What are medication reconciliation and errors?

What can you do?

"We do not have any conflicts of interest to disclose in this presentation."

A study published in the Journal of Hospital Medicine found that 29 minutes of data-gathering by the nurse to create a home medication list and then comparing it with the active inpatient medications averted 81 adverse drug events in 290 patients (Feldman, 2012).

  • ASK your patient if they understand his/her prescriptions.
  • IDENTIFY errors and interactions during review of the patient EMR.
  • TEACH your patient during medication administration about the indication, side effects and safe use of the prescription you are giving to him/her.

What is Medication Reconciliation?

The IHI defines medication reconciliation as:

“…the process of creating the most accurate

list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital.”

This is largely a nursing task, as nurses implement discharge teaching and planning. Instead of assuming the next provider will take care of it, incorporate it into your nursing care.

Think ahead: As a nurse practitioner, med reconciliation is key to providing safe patient care.

  • Computerized Physician Order Entry
  • Safety checks
  • Dosing calculations
  • Double-checks
  • No messy handwriting!
  • Barcode readers
  • Prevent ID, med errors

Electronic Programs

  • Varying dosage calculations
  • Age/weight/conversions
  • Differing side-effects
  • Communication barrier
  • More severe reactions
  • Specialized training required

Error Risk Factors

  • Standardization of administration
  • Proper weight measurement
  • Prevent disruptions
  • Safety checks
  • Electronic prescribing

Pediatrics: A Sensitive Population

Preventing Errors in Kids

Medication management for elderly patients in an academic primary care setting: A quality improvement project

  • Brown bag checkup requires patients to gather ALL meds, including OTC, mail order, or herbal products, into a “brown bag.”
  • “Education played a significant role in increasing medication reconciliation rates and patients brown-bagging medication."

Geriatric Nursing Intervention:

Brown Bagging

  • 44% of men & 57% of women older than age 65+ take 5+ meds/week
  • 12% of both men and women take 10+ meds per week
  • Elderly populations are more susceptible to the adverse effects of polypharmacy due to physiological changes involved in the aging process.

  • Physiological changes & Geriatric Syndrome
  • “…the extent to which patients take medications as prescribed by their health care providers.”
  • Non-compliance: 55% at the first follow-up and 69.6% 3 months from discharge.
  • Only 45% of patients at the first follow-up and 30% 3 months after discharge were taking all medications as prescribed at discharge.
  • “Medication adherence was particularly low among patients receiving the highest number of medications."

Polypharmacy in Elderly Populations

Medication Compliance Among the Elderly

  • Treating the symptoms of adverse effects of one drug with another drug.

Prescribing Cascade

Polypharmacy

The effects of taking multiple medications concurrently to manage coexisting health problems, such as diabetes and hypertension.

What is polypharmacy?

What can you do?

  • Use of the ‘med room’ to prepare (draw, measure, verify) medications
  • Use of WOW tags that indicate meds are being given
  • Training for staff (nurses, physicians, UAP) to eliminate interruptions when WOW tags are displayed unless emergency.

What is a Medication Error?

Defined

The National Coordinating Council for Medication Error Reporting and Prevention (2014) defines a medication error as:

"...any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer."

Approximately 11% of the nurse’s medication administration time is spent dealing with distractions and interruptions.

References

Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2015). Interventions to reduce nurses’ medication administration errors in inpatient settings: A systematic review and meta-analysis. International Journal of Nursing Studies 1-9.

Bower, R., Jackson, C., & Manning, J. C. (2015). Interruptions and medication administration in critical care. Nursing in critical care, 20(4), 183-195.

Carayon P., Wetterneck J., Cartmill R., Blosky M., Brown R., Kim R., … Walker J. (2014). Characterizing the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Quality and Safety, 11 (319), 56-65.

Chhabra, P.T., Rattinger, G.B., Dutcher, S.K., Hare, M.E., Parsons, K.L., &Zuckerman, I.H. (2012). Medication reconciliation during the transition to and from long-term care settings: A systematic review. Research in Social and Administrative Pharmacy, 8, 60-75. doi: 10.1016/j.sapharm.2010.12.002

de Vries, E. N.; Ramrattan, M. A., Smorenburg, S.M., Gouma, D. J., Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review [Abstract]. Quality and Safety in Health Care, 17, 216–23.

Dharmar, M., Kuppermann, N., Romano, P. S., Yang, N. H., Nesbitt, T. S., Phan, J., ... & Marcin, J. P. (2013). Telemedicine consultations and medication errors in rural emergency departments. Pediatrics, 132(6), 1090-1097.

Hanlon, J.T., Semla, T. P., Schmader,K.E. (2014). Medication misadventures in older adults literature from 2013, Journal of the American Geriatric Society, 62 (10), 1950-1953.

Feldman, L. S. (2012). Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. Journal of Hospital Medicine, 7(5), 396-401.

Kaufmann, J., Laschat, M., & Wappler, F. (2012). Medication errors in pediatric emergencies: a systematic analysis. Deutsches Ärzteblatt international, 109(38), 609.

Kaufman, G. (2015). Multiple medicines: the issues surrounding polypharmacy. Nursing and Residential Care, 17 (4), 198-203.

Levinson, D.R., (2010). Adverse events in hospitals: national incidence among medicare beneficiaries. Office of Inspector General, Department of Health and Human Services, 2010.

McComas J., Riingen M., Kim, S. C. (2014). Medication administration record on medication administration efficiency and e rrors. CIN: Computers, Informatics, Nursing, 32 (12), 589–595.

National Coordinating Council for Medication Error Reporting and Prevention. About medica- tion errors. (2014). Retreived from http://www.nccmerp.org/aboutMedErrors.html. http://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx

Patterson, S.M., Hughes, C., Kerse, N., Cardwell, C.R., Bradley, M.C. (2012) Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Systematic Review, 16 (5). doi: 10.1002/14651858.CD008165.pub2.

Pasina, L., Brucato, A.L., Falcone, C., Cucchi, E., Bresciani, A., Sottocorno, M., Taddei, G.C., Casati, M., Franchi, C., Djade, C.D., Nobili, A. (2014). Medication non-adherence among elderly patients newly discharged and receiving polypharmacy. Drugs and Aging 31 (4) 283-289.

Preyde, M., Brassard, K. (2011). Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review, Journal of Evidence Based Social Work. 8 (5) 445-468. doi: 10.1080/15433714.2011.542330

Rinke, M. L., Bundy, D. G., Velasquez, C. A., Rao, S., Zerhouni, Y., Lobner, K., ... & Miller, M. R. (2014). Interventions to reduce pediatric medication errors: a systematic review. Pediatrics, 134(2) 338-360.

Spencer, J. A. (2012). Integrating informatics in undergraduate nursing curricula: using the QSEN framework as a guide. Journal of Nursing Education, 51(12), 697.

Tjia, J., Velten, S.J., Parsons, C, Valluri, S., Briesacher, B.A. (2013) Studies to reduce unnecessary medication use in frail older adults: a systematic review, Presented at Annual National Meeting of the American Geriatric Society, Washington DC May 2011. Springer International Publishing Switzerland doi: 10.1007/s40266-013-0064-1

Topinkova, E., Baeyens, J.P., Michel, J.P, Lang, P.O. (2012) Evidence-based strategies for the optimization of pharmacotherapy in older people, Drugs and Aging 29 (6) 477-494. doi: 10.2165/11632400-000000000-00000.

Vejar, M.V., Flynn Makic, M.B., Kotthoff-Burrell, E. (2013) Medication management for elderly patients in an academic primary care setting: A quality improvement project, Journal of the American Association of Nurse Practitioners doi: 10.1002/2327-6924.12121

Williams, T., King, M. W., Thompson, J. A., & Champagne, M. T. (2014). Implementing Evidence-Based Medication Safety Interventions on a Progressive Care Unit. AJN The American Journal of Nursing, 114(11), 53-62.

Wu, H. F., Yu, S., Lan, Y. H., & Tang, F. I. (2012). Medication errors in emergency rooms, intensive care units and pediatric wards. Hu Li Za Zhi, 59(2), 93.

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