Strategies to Reduce Medication Errors in Ambulatory ... - NCBI - NIH

Strategies to Reduce Medication Errors in Ambulatory Practice Kwabena O.M. Adubofour, MD, FACP; Craig R. Keenan, MD; Ashok Daftary, MD, FACP; Josepha Mensah-Adubofour, MD; and William D. Dachman, MD, FACP Stockton and Sacramento, California and Phoenix, Arizona

Medication errors generally refer to mistakes made in the processes of ordering, transcribing, dispensing, administering or monitoring of pharmaceutical agents used in clinical practice. The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has helped raise public awareness surrounding the issue of patient safety within our hospitals. A number of legislative and regulatory steps have resulted in hospital authorities putting in place various systems to allow for error reporting and prevention. Medication errors are being closely scrutinized as part of these hospitalbased efforts. Most Americans, however, receive their healthcare in the ambulatory primary care setting. Primary care physicians are involved in the writing of several million prescriptions annually. The steps underway in our hospitals to reduce medication errors should occur concurrently with steps to increase awareness of this problem in the outpatient setting. This article provides an overview of strategies that can be adopted by primary care physicians to decrease medication errors in ambulatory practice. Key words: ambulatory practice U medication errors U awareness

© 2004. From Fifth Street Medical Center, Stockton, CA )Adubofour, medical director); Primary Care Residency Program (Keenan, director) and Department of General Internal Medicine (Adubofour, associate clinical professor; Kennan, assistant professor), University of California, Davis Medical Center, Sacramento, CA; Sutter Gould Medical Group, Stockton, CA (Daftary); Glaucoma Section, Department of Ophthalmology, Kaiser Permanente Medical Center, Stockton, CA (Mensah-Adubofour); and Hypertension Services, Maricopa Medical Center, Phoenix, AZ (Dachman). Send correspondence and reprint requests for J Natl Med Assoc. 2004;96:1558-1564 to: Kwabena Adubofour, Medical Director, Fifth Street Medical Center, 1839 S. El Dorado St., Stockton, CA 95206; phone: (209) 466 6871; fax: (209) 466 0502; e-mail: [email protected]

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INTRODUCTION In the United States, an estimated 44,000 to 98,000 deaths annually may be caused by medical errors.' These figures were provided in a report by the Institute of Medicine (IOM). The report documents the fact that medication errors are a major problem in our hospitals and that adverse drug reactions (ADR) remain an important cause of morbidity and mortality. The IOM report estimates that medication errors account for 7,000 deaths per year in the United States. A medication error, defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), is 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. Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use.2 The IOM urges physicians and hospital authorities to begin to put into place those systems and processes that help reduce errors. The recent attention being paid to medical errors is important. Attempts to prevent drug-related errors within hospitals should occur concurrently with efforts being made by primary care physicians to prevent medication-related mishaps in the outpatient setting. The high costs associated with drug-related morbidity and mortality among outpatients in the United States is another important reason for primary care providers to increase their awareness of issues surrounding medication errors. Johnson and Bootman calculated that problems associated with pharmaceutical agents in the outpatient setting accounted for 1 16 million extra visits to the doctor per year, 76 million additional prescriptions, 17 million emergency department visits, 8 million admissions to hospital, 3 million admissions to long-term care facilities and 19,000 additional deaths. The total cost VOL. 96, NO. 12, DECEMBER 2004

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was estimated by the authors to be $76.6 billion.3 These costs will continue to rise as more patients are seen in the outpatient setting. In a survey of nonfederal, office-based physicians, there were 756.7 million office visits during 1999, a 19% increase in the number of visits since 1985.4

Outpatient medication errors may be on the rise. This is suggested by one of the few studies to investigate medication-related deaths. An examination of U.S. death certificates during a 10-year period ending in 1993 found that fatal medication errors had increased from 2,876 deaths in 1983 to 7,391 in 1993,

Table 1. Some Examples of Technology Companies Involved in Drug Databases/ Prescription Writing for Handheld Devices Drug Reference Information

Company

Drug Database

Cost/Features

Epocrates http://www.epocrates.com

QRx

Palm platform/pocket PC. Clinical drug reference guide with point-ofcare information on commonly prescribed drugs. See site for price. Provides formulary information plus other point of care tools. Updated

weekly. Franklin Electronic Publishing http://www.franklin.com

Physicians Desk Reference Pocket PDR

Palm platform/pocket PC. Prescribing information on thousands of medications. Search contents by drug name or key word. Includes built-in spell checker. Updated on regular basis.

Handheldmed.com http://www.handheldmed. com

The Physician's Drug Handbook

Palm platform/pocket PC. Provides data on over 5,000 branded and generic drugs. Info includes pharmacodynamics and pharmacokinetics of drugs.

Memoware http://www.memoware. com

MedicineNet Pocket Guide to Medications

Palm platform. Gives quick and convenient access to important information on common medications to mobile users.

Skyscape http://www.skyscape.com

A2Z drug facts

Palm/pocket PC. Contains more than 600 full drug monographs. Up-to-date info on more than 5,000 drugs. ifacts covers drug interactions.

AllScripts http://www.allscripts.com

AllScripts

Cost varies. Palm/pocket PC. The Prescribe module enables a physician to generate a prescription and have it sent directly to the pharmacy.

PocketScript http://www.zixcorp.com

PocketScript

Palm/pocket PC. Wireless system. Company installs everything gratis. Interfaces with office PC where most of the software resides. Transmits electronically or faxes prescription to the specified pharmacy.

Iscribe Advance PCS https://physician.advance pcs.com

Iscribe

Cost variable. Palm/Windows CE platforms. Permits you to print prescriptions. Software allows you to download information on scheduled patients. Formulary info also available.

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representing a 2.57-fold increase. I This study also noted an 8.5-fold increase in outpatient medication error deaths. Another important finding was the fact that between 1983 and 1993, the number of outpatient visits in the United States increased by 75%, and the number of inpatient days fell by 2 1%.5 The increase in outpatient visits implies that more patients are taking pharmaceutical agents in the outpatient setting without supervision from hospital-based staff. What steps can physicians in primary care ambulatory practice take to reduce medication errors? This question is important because prescriptionerror related malpractice lawsuits are the second most frequent and the second most expensive types of suits filed against physicians. The majority of these claims are against internal medicine and family practice physicians.6 In addition, ProMutual Group, a Massachusetts-based medical malpractice insurer, recently issued a report that showed within 1,085 office claims, 121 claims were for alleged negligence in prescribing or administering of medications, and 44 of these claims resulted in indemnity payments totaling $11.2 million.7 This article discusses strategies that can be adopted in the outpatient setting to minimize medication errors and reduce ADR.

Prevention Strategies for Primary Care Physicians Update knowledge of therapeutics Three key factors were listed by the IOM that contribute to prescribing error: 1) using the wrong drug name, 2) incorrect dosage calculations, and 3) atypical or unusual and critical dosage frequency. It is very easy to use the wrong drug name when prescribing, because so many new drugs enter the market every year. The FDA Center for Drug Evaluation and Research (CDER) approved 98 original new drugs in 2000.8 There are more than 17,000 trade and generic names for pharmaceuticals marketed in North America. Keeping up-to-date and being ready to address drug-related questions posed by patients is becoming increasingly challenging. Formulary A useful approach may be for physicians to create their own "personal" formulary of frequently used medications and become familiar with any new information regarding these agents. Numerous sources of drug information are available to physicians. An important criterion for the use of any source is that it should provide unbiased and up-to-date information. Obtain a personal digital appliance Interested physicians should point their browser 1560 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

to any one of several Internet-based services that allow physicians to download a database of drug prescribing information onto handheld devices for use at the point of care. These handheld devices allow primary care physicians to look up unfamiliar drugs and review ADR as well as perform checks for drug-drug interactions. All this can be performed before the consultation with the patient is over. Epocrates, a leader in electronic drug databases for the Palm platform, estimates that over 600,000 healthcare providers have used their software. Table 1 provides a partial listing of companies providing electronic drug databases.

Electronic prescribing This is one way to decrease some of the potential errors associated with prescriptions. A large number of prescription errors arise as a result of mistakes made in attempting to read the handwriting of physicians. A report from the Institute for Safe Medication Practices noted that, each year, pharmacists make approximately 150 million calls to clarify illegible prescriptions.9 A cardiologist in Texas was ordered to pay $225,000 to the family of a patient who died after receiving Plendil® instead of Isordilg; the pharmacist could not read and did not question the illegible prescription. A 1997 report by the American Medical Association showed that medication errors secondary to misinterpreted physicians' prescriptions were the second most prevalent and expensive claim listed on 90,000 malpractice claims filed over a seven-year period. '0 Electronic prescribing, or e-prescribing, reduces inefficiencies in the prescription writing process and eliminates problems associated with illegibility. Computer technology already exists for prescriptions to be sent electronically to community pharmacies. In addition, several companies are attempting to integrate wireless prescription capability and office-based systems. The attempts at integration hopefully will provide access to patient information relevant to prevention of medication errors (i.e., drug allergies and potential drug conflicts). These devices can also be programmed to check to ensure formulary compliance at the point of care. Table 1 provides a partial list of companies currently involved in ventures to provide clinicians with electronic prescription systems.

Steps to reduce prescription writing errors Primary care physicians should review the five "rights" of prescription writing with each patient encounter-right patient, right drug, right time, right dose, and right route. If prescriptions are to be handwritten, physicians should take the following specific steps to avoid making any errors:

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* clearly state patient's name * provide the generic and brand name of the drug whenever possible and avoid abbreviations * write out the drug strength in metric units and never leave a decimal point "naked" nor use a "trailing" zero (e.g., write "0.1 mg" instead of".1 mg" and "1 mg" instead of"1.0 mg") * state the dosage form and the amount to be dispensed * directions for use should be clearly stated and lastly, * if patient confidentiality is not an issue, state the purpose of the medication.

Prescribe medications only when necessary While this statement may seem obvious, some physicians have prescribed medications because of patient demand. Direct-to-consumer drug advertising, now commonplace, may place undue stress on many physician-patient relationships. Primary care physicians should resist the temptation to prescribe at the insistence of patients and should educate patients about the clinical reasoning behind the use or nonuse of specific agents. Take a drug history/document drug allergy A poor drug history may lead to a failure to detect unintended drug effects. A drug history should include the use of alternative medicines or herbal medications, supplements and other over-the-counter (OTC) medications. A recent study indicated that review and documentation of nonprescription substances are uncommon in primary practice." Of 655 physician respondents, only 47% documented herbal and other

alternative treatments in the medical record." Physicians should always ask patients about allergies to drugs and should make sure the allergy history has been clearly documented and prominently displayed on the front of the patient's chart. When a doctor prescribes a new medication, he/she should always be sure to ask if the patient has used the drug before and if any unpredictable reaction occurred. Physicians should encourage patients with serious allergic reactions to wear medic alert bracelets or necklaces. Keep your medication/drug list up-to-date The maintenance of a medication list is a vital link in alerting the physician to possible drug-drug as well as drug-disease interactions. Physicians need to be mindful of the possibility of drug interactions as new medications are added. It is important to remember to add to the chart medications being provided by subspecialists. Conduct medication reviews periodically in your practice and recruit the help of local pharmacists in this endeavor to ensure that your patients are taking the right medications safe from preventable errors. Have patients who are on multiple drugs-especially ifelderly-bring medications to follow-up visits Elderly patients especially are more prone to ADR. They are dealing with multiple, complex medical problems requiring several agents. In addition, the normal physiologic changes that occur with aging place the elderly at increased risk for ADR (Table 2). Primary care physicians will be faced with an ever- increasing elderly population given the projected demographics of the next several years, so understanding some basic

Table 2. Geriatric Clinical Pharmacology Some Important Physiologic Changes Impacting Drug Effects in the Elderly

Physiologic Change

Example of Drug Effect

Reduction in lean body mass

Drugs, such as digoxin, which bind to muscle Na/K ATPase may have an increased effect in the elderly on account of reduction in lean body mass and resulting decrease in volume of distribution.

Increase in proportion of adipose tissue with aging.

This results in many lipid-soluble drugs having a more prolonged half-life in the elderly. This has clinical relevance when prescribing agents that act on the central nervous system.

Decrease in plasma proteins and declining levels of hepatic drug metabolizing enzymes.

Albumin levels decrease in the elderly and, as a result, a more active drug is available to exert therapeutic as well as unwanted effects.

Decrease in glomerular filtration.

The physiologic decrease in glomerular filtration may result in a deficiency of drug processing ability and impairment of drug elimination, placing the elderly at risk of adverse drug effects.

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facts and principles of geriatric clinical pharmacology should be considered an important primary care issue. A few numbers should help illustrate this point. Although persons aged 65 and older represent only 12% of the population, they account for more than 25% of prescription medications consumed in the United States12 Elderly individuals use, on average, 4.8 prescriptions and OTC medications on a daily basis.'3 These numbers also mean that polypharmacy and possible drug-drug interactions are important issues for the elderly in the outpatient setting. Pay attention to the use offixed-dose combination medication products in the elderly and other patients Physicians should always document the active ingredient in such combinations in the medication list to prevent potential problems. Note that some elderly patients may use multiple doctors as well as pharmacies. Physicians may need to work with such patients to make it easier to manage and coordinate their medications by discussing use of a single pharmacy, if at all possible. Patients should be encouraged to make a list of all current medications. Table 3 outlines important principles to enhance medication use in elderly patients. Pay attention to drug labels It is important to remember that drug labeling details can change as new information is obtained. The Food and Drug Administration (FDA) issues a "black box" warning on labels to alert clinicians to drugs remaining on the market with serious adverse

events. These boxed warnings alert physicians to any special restrictions or mode of administration of specific agents. It is especially important to have patients read the labels with each medication refill. New drug information is available at the FDAs website: http://www.fda.gov/medwatch/. In addition to label education, primary care physicians should make sure patients understand the rationale for the use of certain medications. Physicians should devote time to explain the disease process and any expected outcome of drug treatment to their patients. Both acceptable and unacceptable effects of medications should be explained to patients to help increase the chances of adherence to the prescribed regimen. Educating patients enhances their role in preventing medication errors. Alert and knowledgeable patients can serve as the last line of defense in preventing medication-related errors. In short, educate before you medicate. Enlist the help oflocalpharmacists and encourage patients to askpharmacists about their medications andADR Physicians should remember that they have a good source of drug information in local pharmacists. Patients as well as physicians should actively interact with pharmacy personnel to obtain drug information. Physicians should work with local pharmacists to minimize medication errors. This becomes especially important in patients who see other physicians and use multiple pharmacies. Physician-pharmacist interaction should be made to work for the good ofour patients.

Table 3. Geriatric Clinical Pharmacology Promoting Safe Medication Use in the Elderly in Primary Practice O Review all drugs on your medication list at each clinic visit for your elderly patients. Eliminate those not required. Discourage elderly patients from sharing the medicines of friends and family members. O Have pharmacies provide your elderly patients with large-print labels and collaborate to educate patients about adverse drug reactions and other drug effects. O Encourage your elderly patients to bring friends or family members to clinic visits for additional "memory" support. O Encourage the use of devices, such as drug calendars and pill boxes, and the use of open containers.

O Wherever possible, use simple dosing schedules to improve compliance. O Have patients disclose use of supplements and OTC medications at each clinic visit. O Have elderly patients bring all medications to each clinic visit for review. Encourage discussion of

nonpharmacological alternatives. O Check each new symptom/complaint for drug-induced disease in your elderly patients. O Remember that for elderly patients you may have to "start low and go slow" and use the lowest possible drug dose to achieve the desired response.




Verbal orders over the phone should always be repeated by the pharmacists before the call is considered complete. Physicians need to be aware of "sound alike" drugs when making phone calls. To limit errors, the indication for the use of any agent called in should also be discussed with the pharmacist. In addition, automatic refills of certain medicines should only be encouraged if constant review mechanisms are in place at the offices of the primary physician and the pharmacist to avoid ADRs.

Improve knowledge ofcommonly used herbal therapies Primary care physicians should attach some importance to the issue of keeping up-to-date with the changes going on in the realm of herbal therapy. The use of herbal or natural products is growing significantly in this country. Americans spend approximately $3 billion annually on herbal products.14 Physicians need to know that some patients do not consider herbal supplements to be medicinal agents and will not provide a history of use unless specifically asked. As noted by Jaski et al., review and documentation of nonprescription substances are uncommon in primary care practice." Primary care physicians should realize that the review and documentation of all medications at each visit can be an effective safeguard against medication errors. Physicians need to become familiar with commonly used herbal agents. Doctors need to know the potential therapeutic benefits of these agents. Doctors also need to know if patients are being exposed to harm by utilizing these herbal preparations. The nature of such risks and the potential for drug-drug and drug-disease interactions should be studied. A good reference for this is Natural Medicines Comprehensive Database published by Therapeutics Research (http://www.naturaldatabase.com). Be aware ofdangerous drug-drug interactions: ask about consumption ofgrapefruit juice/Improve your basic knowledge of the cytochrome P450 drug metabolizing system In a survey of potential drug interaction incidence in an outpatient clinic setting, Stanaszek and Franklin reported an adverse drug reaction rate of 23%.'1 The key to avoiding harmful drug interactions is to recognize and monitor patients at high risk. Elderly patients are at the greatest risk of drug interactions because they take multiple medications for a variety of reasons. The following medications should be closely monitored for potential interactions when given with other agents to elderly patients; antiarrhythmic agents, antacids, antipsychotics, calcium antagonists, centrally acting analgesics, digoxin, diuretics, nonsteroidal anti-inflammatory drugs, oral hypoglycemic agents, phenytoin, theophylline, tricyclic antidepressants and coumadin. Patients who see other prescribing specialists are also at high risk, and it is JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

important to review all medications after a patient returns from a specialist consultation. Beware of interactions involving grapefruit juice. Drugs that interact with grapefruit juice undergo cytochrome P450 oxidative metabolism in the intestinal wall or liver. Grapefruit juice contains furanocoumarin derivatives that inhibit metabolism by CY 1 P3A. Grapefruit juice increases the serum drug concentration of amiodarone, astemizole, cyclosporine, carbamazepine, midazolam, diazepam, lovastatin, simvastatin, atorvastatin, verapamil and the dihydropyridine calcium channel blockers.16 Physicians need to be aware that some herbal medications may induce toxicity via the cytochrome P450 pathway. Herbal supplements known to have cytochrome P450 enzyme activity include kava, Ginkgo biloba, chili pepper and black pepper. Drugs metabolized at the level of cytochrome P450 generally have one of two effects, enzyme inhibition or enzyme induction. For commonly prescribed drugs, primary care physicians should anticipate drug Table 4. Partial List of Websites with Special Focus on Medication Errors * AHRQ Medical Errors and Patient Safety Research Page

http://www.ahcpr.gov/qual/errorsix.htm * American Hospital Association

http://www.aha.org/medicationsafety/ medsafety.org * American Society of Health-System Pharmacists

http://www.ashp.org/patientLsafety/ index.html * Institute for Safe Medication Practices

http://www.ismp.org * Mederrors.Com

http://www.mederrors.com * National Coordinating Council for Medication Error Reporting and Prevention http://www.nccmerp.org

* National Patient Safety Foundation

http://www.npsf.org * Institute for Healthcare Improvement

http://www.ihi.org * Quality Interagency Coordination Task Force

http://www.quic.gov * U.S. Pharmacopoeia

http://www.usp.org

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interactions by familiarizing themselves with the effects of these agents on the P450 enzyme system. Maintain vigilance and review the drug list of patients reporting new symptoms on initiating additional drug therapy. Do notforget drug-disease interactions As a classic example, the patient with chronic obstructive pulmonary disease (COPD) who presents with worsening symptoms may be on a beta-adrenergic blocking drug. In addition to COPD, beta-adrenergic agents can often precipitate and cause exacerbation of diseases, such as asthma and peripheral vascular disease. Elderly patients on drugs causing anticholinergic effects may present with worsening lower urinary tract symptoms of benign prostatic hyperplasia, constipation and glaucoma. The adverse effects, dry mouth, urinary retention and confusion caused by some of these anticholinergic agents warrant their constant review in elderly patients. The symptoms above and others, such as lethargy, weakness, falls and dizziness, should always prompt review of medications in an attempt to avoid the prescribing cascade that occurs when additional drugs are prescribed to treat drug-induced symptoms.'7

5. Phillips DP, Christenfeld N, Glynn LM. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644. 6. Medication Error Study, June 1993. Physician Insurers Association of Amerca, Washington DC. 7. Greenwald L. Medical Error in the Physician Office: An Insurer's Perspective. Medicine and Health/Rhode Island. 2000:83:312-315. 8. Making Medical Progress-A Look at FDA Approvals in 2000. FDA Consumer, March 2001, v35 i2 p7. 9. Institute for Safe Medication Practices. 'White paper on electronic prescribing.' 2000. http://www.ismp.org. 10. Cabral JD. Poor physician penmanship. JAMA. 1997;278:1 116-1117. 11. Jaski ME, Schwartzberg JG, Guttman RA, Noorani M. Medication Review and Documentation in Physician Office Practice. Effective Clinical Practice. 2000;3:31-34. 12. Schwartz JB. Geratric clinical pharmacology. In: Kelly W, ed. Textbook of Internal Medicine. 3rd ed. New York. NY: Lippincott-Raven. 1997:2547-2554. 13. Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons. Arch Intem Med. 1994;154:2195-2200. 14. Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-75. 15. Stanaszek WF, Franklin CE. Survey of potential drug interaction incidence in an outpatient clinic population. Hosp Phorm. 1978;13:255-263. 16. Clifton GD. Grapefruit Juice-Drug Interactions: Not Just Pulp Fiction. CVR & R. 2000;1 1-12. 17. Rochon PA, Gurwitz JH. Optimizing drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315:1096-1099. A

CONCLUSION Physicians engaged in ambulatory practice need to be proactive in making the use of medications safer. It is only through constant vigilance that doctors can decrease the incidence of ADR and medication errors. They should work with patients and other healthcare providers to reduce the number of errors in prescriptions and drug administration. They must also participate in the postmarketing surveillance program established by the FDA. The MedWatch program (1-800-FDA- 1088, http://www.fda.gov/ medwatch/report/hcp.htm) is the safety information and adverse event reporting program of the FDA. MedWatch is important since the data generated can only lead to more prudent prescribing. For physicians wishing to obtain further information on medication errors, Table 4 provides a list of websites that contain relevant information on this subject. Most of these websites provide various resources, references and links to sites aimed at patient education as well.

REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, ed. To Err Is Human. Committee on Quality of Health Care in Amerca. Institute of Medicine. Washington DC. 1999. 2. http://www.nccmerp.org/aboutmederrors.html. Accessed on April 10, 2004. 3. Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997; 54:554-558. 4. http://www.cdc.gov/od/oc/media/pressrel/r01071 7.htm. Accessed December 8,.2001 .


Candidates (MD or PhD) are invited to apply for a position beginning July 2005 as a fellow in the Division of Clinical Pharmacology, Thomas Jefferson University. This NIH-supported training program provides expertise in the principles and practice of clinical pharmacology and clinical investigation. The program, including didactic, clinical, and basic research components, requires a minimum of 2 years after which fellows will be subspecialty board-eligible. Candidates should address inquiries to: Training Programs, Division of Clinical Pharmacology, Thomas Jefferson University, 132 South 1 0th Street, 1 1 70 Main, Philadelphia, PA 19107. Applications from members of minority groups are strongly encouraged. AAEO.
