Medication Safety in the Primary Care Setting

1. Medication Safety in thePrimary Care Setting Frank Federico Executive Director Institute for Healthcare Improvement This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

2. Learning Objectives By the end of this module you will be able to: • Describe the importance of medication safety in the primary care setting • Identify areas in need of improvement • Use concepts described to begin to develop a medication safety improvement project

3. Concerns About Medication Safety More than half of American adults take at least one prescription medication daily Sources: www.myhealthnewsdaily.com/3069-prescription-drugs-2011.html (4/9/2012) Kaufman et al. 2002

4. Concerns About Medication Safety More than half of American adults take at least one prescription medication daily About 4 billion prescriptions for medications were written in 2011 Sources: www.myhealthnewsdaily.com/3069-prescription-drugs-2011.html (4/9/2012) Kaufman et al. 2002

5. Concerns About Medication Safety More than half of American adults take at least one prescription medication daily About 4 billion prescriptions for medications were written in 2011 Approximately two out of every three office visits result in a prescription written Sources: www.myhealthnewsdaily.com/3069-prescription-drugs-2011.html (4/9/2012) Kaufman et al. 2002

6. Elderly and Their Medications Sources: www.myhealthnewsdaily.com/3069-prescription-drugs-2011.html (4/9/2012) Kaufman et al. 2002 6

7. Medication Errors: Ambulatory Setting Gurwitz JH, et. al. Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting. JAMA. March 5, 2003;289(9):1107-1116. 7

8. Evidence of Medication Errorsin the Primary Care Setting • 25% (162/661) primary care patients had ADE • Of those 162 patients • 13% (24) serious • 11% (20) preventable • 28% (51) ameliorable • 06% (13) both serious & • preventable or ameliorable Gandhi TK, et al. NEJM April 2003

9. What Should We Worry About? “High-alert” medications Out-of-date side effect & drug interaction info Out-of-date medication and allergy lists Therapeutic duplication Adjustment for renal failure and pregnancy

10. Institute for Safe Medication Practices 10 www.ISMP.org Accessed August 2013

11. Situations Leading to Medication Errors Omitting a drug patient should be taking • Example: Anticoagulant stopped for inpatient stay and not restarted after surgery Overlooking medications as cause of patient problem • Example: Patient prefers to color code her medication Providing ineffective/incomplete instructions • Example: Assuming patients understand the instructions or warning labels on prescription bottles

12. Situations Leading to Medication Errors Failing to ask if patients • Are taking their medication at all • Example: Patient stopped taking medication because of side effects, but does not tell doctor. • Are taking their medication as prescribed • Example: Patient is taking less medication to save money, but does not tell doctor • Are taking medication from other doctors • Example: Patient started new medication after visiting a specialist, but does not tell doctor

13. PROMISES Driver Diagram

14. Useful Interventions • Track patients on high-alert medications • Monitor blood values • Monitor side effects • Ensure access to latest drug info database • Reduce “polypharmacy” • Apply lessons from follow up of lab results to medication monitoring 14

15. Useful Interventions Implement a reliable medication follow-up process to address knowing about: • New prescriptions from other providers • Discontinued medications by other providers • Therapeutic duplication • Medications that may interact • Non-adherence by patients • Medications that require monitoring 15

16. Useful Communication Interventions Deliver instructions and materials in a patient centered literacy appropriate level • Examples: AHRQ website and Massachusetts Coalition for the Prevention of Medical Errors website

18. Useful Communication Interventions Engage patients/families/caregivers when deciding therapeutic plans • Example: Ask a patient: • What is the matter with you? • What matters to you? • What will you be able to manage?

19. What is the Patient Really Taking? Problem: • Patient has unexplained symptoms Action: • Patient asked to bring all medications in Finding: • Patient was arranging & taking pills by color!

20. Test: Bring in all your Scripts! • Problem: Determine if patients with memory & dementia issues are taking medications correctly • Action: Asked these vulnerable patients to bring • in all medications for a medication “check-up” • Finding: Provided opportunities to talk with patients and test if using pillboxes made it easier to take medications correctly

21. Are Medication & Allergy Lists Updated? Finding • Only 3 medication lists (19%) were updated • Only 6 allergy lists (38%) were updated • None of the 16 had both updated! For 16 patients, Practice Manager checked Allergy lists, medication lists

22. Change when the medication lists are reviewed Print medication list prior to patient visit (MA) Review medication list prior to huddle (MD, MA) Review list with patient Make changes when provider indicates Test: Medication List Review Protocol

23. What Can You Do Today? Check: Reliable process for updating patient medication lists? 23

24. What Can You Do Today? Check: Reliable process for updating patient medication lists? • Measurement strategy: Review medical records • Was medication list reviewed and updated? 24

25. What Can You Do Today? Check: Reliable process for updating patient medication lists? • Measurement strategy: Review medical record • Was medication list reviewed and updated? Check: Reliable process to update patient allergies? 25

26. What Can You Do Today? Check: Reliable process for updating patient medication lists • Measurement strategy: Review medical record • Was medication list reviewed and updated? Check: Reliable process to update patient allergies • Measurement strategy: Review medical records • Was allergy information reviewed & updated? 26

27. Thank You! Thank you for your time and attention today

28. A Few References Institute for Healthcare Improvement www.ihi.org Institute for Safe Medication Practices http://ismp.org/ Massachusetts Coalition for the Prevention of Medical Errors http://www.macoalition.org/reducing_medication_errors.shtml 28