Medication Errors: Following the Script.

INTERVIEW WITH DR. JERRY H. GURWITZ

Nursing home residents rely on caregivers to handle their medication needs-everything from ensuring the proper dosage to checking for unexpected reactions when multiple medications are taken. This is no small challenge, since nursing home residents receive an average of six different drugs; staff must juggle each resident's prescription laundry list along with all the other care he or she needs. Unfortunately, but perhaps not surprisingly, mistakes do happen.

In a cohort study of 18 community-based Massachusetts nursing homes,' researchers identified 546 medication-related adverse events and 188 potential adverse events for 2,916 residents. The researchers classified these events as "significant," "serious," "life threatening" or "fatal."

Of the 546 adverse drug events that occurred, approximately half (51%) were considered preventable; 1 resulted in death; 31 were considered life threatening; 206 were rated as serious and 308 were deemed significant.

Psychoactive medications (antidepressants, antipsychotics and sedatives/hypnotics),as well as anticoagulants, were the drugs most often associated with preventable adverse drug events. Of both the preventable and nonpreventable adverse drug reactions, neuropsychiatric events, such as oversedation, confusion, hallucination and delirium, occurred most frequently.

The researchers also discovered that errors leading to preventable adverse events took place more commonly in the ordering and monitoring of medications than in transcription of prescriptions or in dispensing and administration of medications.

Generalizing their findings to all nursing homes in the country, the researchers state, "...About 24 adverse drug events and 8 potential adverse drug events should be identifiable each year in an average facility, many of which should be preventable. Thus, about 350,000 adverse drug events-more than half of which are preventable-occur each year in the 1.55 million residents of U.S. nursing homes. There are almost 20,000 fatal or life-threatening adverse drug events per year, of which 80% are preventable."

While these statistics paint a rather grim picture, the researchers emphasize the need to help nursing homes handle medications properly, not simply admonish them. Reflecting on the study and suggesting ways for facilities to improve is the report's lead author, Dr. Jerry H. Gurwitz, who recently talked with Nursing Homes/Long Term Care Management Assistant Editor Douglas J. Edwards.

Edwards: What needs to be done to reduce the frequency of medication errors in nursing homes?

Dr. Gurwitz: First, the entire culture of the nursing home setting needs to change, as do all clinical settings. There's definitely a lack of recognition that these problems occur. Second, there needs to be an environment where nursing home staff can report medication errors without fear of punitive actions, which is the traditional way we have addressed these problems in the past.

Finally, there needs to be a greater awareness of what an adverse drug event actually is. In many cases, they are not recognized, since adverse drug events among the frail elderly can be fairly complex. For example, a fall might be related to exposure to a blood pressure medication or a sedative, but it might be attributed to a resident's arthritis or underlying gait instability. In many long-term care facilities the idea of an adverse drug event is limited to a rash from antibiotic therapy, and clearly our research has shown that adverse drug events are much more varied than that.

Nursing homes should set up committees with some expertise that can analyze events such as drug-related falls, bleeds, etc., and look for their root causes and ways to prevent them from happening again.

Edwards: Your report says, "...Educational efforts about the optimal use of drug therapies in frail elderly patients are essential." Could you expand on this?

Dr. Gurwitz: The staff clearly needs to be educated about what types of things need to be reported to the facility administrator, nursing director or medical director. Most of the events we uncovered would have never been reported, because staff either did not recognize them as adverse drug events or felt that they did not need to be reported.

At this point we really are not sure how CNAs should be educated on this topic; however, what has worked in other settings is to use specific examples of medication errors that occurred in a facility, without identifying the resident and specific staff members involved. That's how staff will learn which types of events need to be reported and what strategies can prevent them from happening again. In fact, any new symptom in an elderly person could be an adverse drug event and should be approached that way.

Edwards: Your research team found that 80% of potential adverse drug events were associated with the blood thinner warfarin. What's the reason for this?

Dr. Gurwitz: Warfarin is a fairly commonly used drug in long-term care settings. Our research found that at least 12% of nursing home residents are on this drug at any one time. Yet there's more to using warfarin than just prescribing it. It requires careful monitoring, because the drug interacts with many other medications, and there are a lot of places in the management of this drug where errors can occur [see sidebar].

This is a situation in which a systems-based approach might reduce the incidence of adverse drug events or near misses. For example, an anticoagulation clinic or service could manage all the residents on warfarin in the facility, or an individual nurse or pharmacist could be assigned the responsibility of overseeing each resident in the facility who is receiving warfarin therapy. There are probably other drugs that should receive the same attention as warfarin, but this drug is really the "poster child" for this topic.

Edwards: Since your study has been published, have there been any formal efforts undertaken to help reduce medication errors in long-term care facilities?

Dr. Gurwitz: There is certainly a lot of funding going into this area. In fact, we've been funded to develop an intervention using computerized physician order entry at two sites-one in Connecticut, the other in Ontario. The idea is to prevent adverse drug events and near misses by giving the prescribers information when the order for a new drug is written. The study compares the rates of adverse drug events or near misses in units where the computerized system is in place with those where it is not.

We're going into this three-year project with the premise that we're not sure whether it's going to work. There's a strong belief that these types of efforts will automatically solve the problem of medication errors, but the programs are fairly expensive to mount. Thus, research such as our intervention study is needed before facilities should really start embracing them. They do work in the hospital setting, but we are not sure of their effectiveness in the ambulatory and long-term care settings, because there are different populations of patients and drugs involved.

Edwards: Any final thoughts for our readers?

Dr. Gurwitz: If members of the long-term care industry don't address medication errors now, they will be forced to later, perhaps by regulatory agencies. They really should try to get ahead of the curve on this issue. NH

Dr. Gurwitz is executive director of the Meyers Primary Care Institute, a joint venture by the University of Massachusetts Medical School and the Fallon Healthcare System in Worcester, Mass.

Reference

(1.) Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. American Journal of Medicine 2000;109(2):87-94.

A Consultant Pharmacist's Perspective

A consultant at three nursing homes and overseeing clinical service at 62 facilities, Brian Stwalley, PharmD, CGP, vice-president of Clinical Services at Continuing Care Rx, is not surprised by Gurwitz et al's finding that 80% of potential adverse drug events were associated with the blood thinner warfarin. He feels there are several factors that contribute to this risk.

Warfarin is a drug with a narrow therapeutic index, meaning a specific blood level of the medication must be achieved for it to be effective yet not toxic to the patient. This can be problematic since, as Dr. Stwalley points out, "an individual's response varies widely" and cannot be predicted simply by examining a patient's age, sex or weight. Further complicating. the situation, many patients are on an "alternating dose regimen," in which a patient might receive a 2-mg dose of warfarin on Tuesday, Thursday, Saturday and Sunday, but 2.5 mg on Monday, Wednesday and Friday.

"I've always been an advocate of trying to get residents on a single daily dose of warfarin to try to prevent the potential for dispensing and administration errors," says Dr. Stwalley, pointing out that the pharmacy might have to split standard tablets to achieve the proper dosages.

Warfarin has multiple food and drug interactions, as well. "It's very important to note that several antibiotics can dramatically increase the effects of warfarin, so you have to be aware of the potential interaction and monitor more aggressively during that time period," explains Dr. Stwalley. Even changing the level of vitamin K in a patient's diet can alter the effect of warfarin.

Because of all these factors in the management of warfarin and other drugs, Dr. Stwalley says certified nursing assistants (CNAs) are important team members in identifying and preventing adverse drug events. He advises that when monitoring residents receiving warfarin, "They [caregivers] need to be particularly aware of the potential for bleeding or bruising. This means thatusing a soft toothbrush and shaving with electric razors are interventions that might help prevent an adverse event," adding that aside from warfarin, CNAs' observations are also especially valuable when psychoactive drugs are prescribed; CNAs' constant interaction with residents allows them to monitor the effectiveness and possible side effects associated with the medications, and CNAs should be coached specifically on the side effects to watch for.

Face-to-face interdisciplinary communication is another way to help identify and reduce the incidence of adverse drug events, suggests Dr. Stwalley. He advises caregivers to conduct regular meetings with the consultant pharmacist and the medical director to specifically review which residents are receiving psychoactive medications and other medications that have been identified as having a high risk of side effects in the elderly.

However, when face-to-face communication is not possible, Dr. Stwalley says it is also important to communicate efficiently. Staff should determine, for example, if physicians prefer faxes or phone calls about changes in a resident's condition, and doctors generally prefer to be contacted once or twice about several residents' conditions instead of being called about individual residents more frequently. Dr. Stwalley has observed physicians having a better relationship and respect for the caregivers when they receive efficient communication and, of course, their residents receive higher quality care.

Douglas J. Edwards