# Presentation: 377697

## Spotlight Case September 2005

**Double Trouble**

## Source and Credits

- This presentation is based on the Sept. 2005 AHRQ WebM&M Spotlight Case
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Jerry H. Gurwitz, MD**, University of Massachusetts Medical School
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- Appreciate the incidence of adverse drug events in older persons
- List preventative measures that can be used to minimize medication errors in this population
- Encourage patients to take an active role in their pharmaceutical care

## Case: Double Trouble

*A 79-year-old man with diabetes mellitus was admitted to the hospital with hypoglycemia. His medication regimen included Glucovance, a combination of metformin and glyburide. Upon discharge, the patient was instructed to stop the Glucovance, and to begin monotherapy with Glucophage (metformin).*

## Case (cont.)

*A few weeks after his hospitalization, the patient presented to the emergency department (ED) with mental status changes. A fingerstick glucose test was 40 mg/dL. According to the patient, his only medication was Glucophage. The patient recalled an occasional skipped meal. He did not recall taking extra doses.*

## Adverse Drug Events (ADEs) in the Elderly

- ADEs occur at a rate of 50 per 1000 person-years among elderly patients in ambulatory setting (14% preventable)
- Generalized to entire Medicare population
- 1.9 million ADEs per year
- 180,000 life-threatening or fatal ADEs per year
- Of these, more than 50% preventable

*Gurwitz JH, et al. JAMA. 2003;289:1107-1116.*

## Factors Contributing to ADEs in Elderly

**Transitions in care**
- After discharge 19%-23% of patients will experience an adverse event
- 1/3 preventable—due to an error
- 1/3 ameliorable—closer monitoring could have reduced severity

*Forster AJ, et al. CMAJ. 2004;170:345-349.**Forster AJ, et al. Ann Intern Med. 2003;138:161-167.*

## Examples of ADEs After Hospital Discharge

*Forster AJ, et al. CMAJ 2004;170:345-349.*

| Type | Adverse Event |
| --- | --- |
| Ameliorable | Antibiotic-associated diarrhea, leading to dehydration and syncope, in a patient treated for pneumonia. The patient was readmitted to hospital and given fluids intravenously; the antibiotic therapy was stopped. |
| Preventable | Profound hypoglycemia necessitating readmission, which developed days after discharge in a patient treated orally with hypoglycemics. |
| Not preventable or ameliorable | Antibiotic-associated nausea, which was self-limiting. |

## Decreased adherence
Adherence has not been an issue in studies of ADEs in hospitalized patients because pharmaceutical care is presumed to be supervised
In the ambulatory setting, responsibility falls to patient or family members
Impact of adherence on ADEs has not been documented but is likely an important factor

- Adherence has not been an issue in studies of ADEs in hospitalized patients because pharmaceutical care is presumed to be supervised
- In the ambulatory setting, responsibility falls to patient or family members
- Impact of adherence on ADEs has not been documented but is likely an important factor

**Factors Contributing to ADEs in Elderly**

## Case (cont.)

*Upon review of the patient’s medication bottles, the ED staff found he was actually still taking Glucovance, not Glucophage as instructed. *

## Improving Medication Safety in the Elderly

- “Start low and go slow”
- Anticipate confusion from sound-alike, look-alike medications
- Provide careful instructions to patients regarding medications
- Facilitate accurate information transfer at times of transition of care

## “Start Low and Go Slow”

- In an elderly patient with diabetes:
- Start with a single agent at a low dose
- Slowly advance to achieve adequate control of glucose
- Add a second agent only if necessary

## Anticipate Medication Confusion

- Combination medications
- Offer advantage of simplifying multidrug regimen
- Single pill may be mistaken for a single drug
- Sound-alike medications
- IOM recommended that FDA require drug companies to test proposed names to identify potential confusion
- Point out possible confusion to patient in advance

*To Err is Human: Building a Safer Health System; 2000.  *

**Notes:**
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 

## Provide Careful Instructions for All Medications

- Patient education is critical to adherence, may be important means of preventing errors
- Health care providers expected to provide comprehensive information but often rushed
- Use multidisciplinary approach to education process

## Medication Reconciliation at Transitions of Care

- Reconciliation: “process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system.”

*Medication Reconciliation Review.*

## Medication Reconciliation at Transitions of Care

- Should take place with every transition
- ICU to floor transfer
- Hospital to rehabilitation center
- Home to hospital
- Hospital to ambulatory care setting
- Involves simultaneous review of previous medication lists with current medication lists

*Medication Reconciliation Review.*

## Medication Discrepancy Tool

*Produced by Care Transitions Program at University of Colorado at Denver and Health Sciences Center*

## ISMP and Safety

- Institute for Safe Medication Practices (ISMP) aims to provide error-reduction strategies to the health care community, policymakers, and the public
- Recommends that patients ask physicians to explain generic and brand names, proper spelling, and indication for each medication

## ISMP Recommendations

- Patients should schedule a **"brown-bag check-up"**
- A dedicated time to review all current prescribed and over-the-counter medications, which they should bring to their primary care physician’s office

*How to Take Your Medications Safely. **Request a Brown-Bag Check-up. *

## Take-Home Points

- When prescribing medications for older persons “start low and go slow.” However, provide elderly patients with the full benefits of an optimal therapeutic regimen, including the use of adequate drug doses and multi-drug regimens when required

## Take-Home Points

- The prescribing physician should be vigilant for sound-alike and look-alike confusion with generic and brand drug names and point these out to the patient
- Patients should be made aware if a single pill contains more than one medication
- Medication reconciliation should be performed routinely at transitions of care

## Take-Home Points

- Multidisciplinary interventions to reduce medication errors should be considered during transitions of care
- Older persons should maintain an active role in monitoring their medications and insist on complete information about their regimen
- Periodic “brown-bag check-up” may reduce adverse drug events