Reducing Medication Errors in Long-Term Care.

BASED ON AN INTERVIEW WITH JACOB DIMANT, MD

Medication errors are getting high-level attention these days, and the American Medical Directors Association has come up with a plan for reform

Earlier this year, the American Medical Directors Association (AMDA) released the findings of a consensus conference on medication management. The White Paper on Quality Pharmaceutical Care in Long Term Care was issued on the heels of an Institute of Medicine (IOM) report, Senate hearings and a White House announcement--all focusing on medication errors. A more recent study, published in The American Journal of Medicine, suggested that the residents of the "average" (106-bed) nursing home will experience 24 drug-related injuries per year and that total incidence of such injuries nationwide in American nursing homes is 350,000. The AMDA paper discusses the challenges that long-term care providers face in administering medications and lays out a system wide framework for reducing errors. The AMDA's National Forum on Quality Pharmaceutical Care in Long Term Care, established in 1998, authored the paper, and Forum Co-Chair Jacob Dimant, MD, recently discussed it in an interview with Nursing Homes/Long Term Care Management.

What factors necessitated the "White Paper on Quality Pharmaceutical Care in Long Term Care"?

Dr. Dimant: There were two factors. The first was a study done in Texas by the Office of Inspector General (OIG) alleging the inappropriate use of medications in nursing homes. The AMDA objected to this study because it was conducted by polling consultant pharmacists and excluded physicians. The AMDA felt that it needed to respond. That study did point to a problem, however, even though it was somewhat biased. The AMDA thought it would be good to respond proactively rather than negatively.

The second factor is that in OBRA '87, HCFA had, for the first time, issued detailed guidelines as to how physicians should use certain medications. They primarily addressed psychoactive and sleep medications. More recently, though, HCFA had started to look at creating a list of medications that should not be used in nursing homes. This was the "Beers List," inspired by an article by Mark H. Beers, MD. The article essentially presented. a list of medications that should "never be used" for the elderly, including a list of medications that can interact with certain diseases that the patient might have and could, therefore, cause an adverse reaction (ADR). HCFA was working to integrate the Beers paper into surveyor guidelines.

The AMDA thought that it would be more appropriate to create a system to correct problems with pharmaceutical care. Instead of just coming up with a list of medications that "should not be used," we should look at the process by which long-term care residents are prescribed medications--how the nursing homes get the drugs, distribute them, and monitor them and their effects--and then come up with an ideal process.

By the time we convened the conference, HCFA had already produced the list. Nonetheless, we wanted to come up with an ideal process that we thought would be a much better way to address the problem.

What did you find are the primary causes of medication errors in long-term care settings?

Dr. Dimant: There are medications that are often used for younger people but might cause serious side effects in the elderly. For example, a medication such as Valium should indeed never be used in older people because the drug accumulates and remains in an older person's body for a longer period of time. A correlation has been shown between elderly people taking Valium and falling.

Some medications are not used enough. For example, there was a concern that residents with depression were not getting enough treatment, although newer data suggest that this is no longer a problem and perhaps there is even overuse in this area.

Then there are medications that interact with each other in various ways. They can either increase or decrease each other's levels or effects and might, in the process, cause an adverse reaction.

There are also medications that interact with a condition the resident might have. For example, certain medications can aggravate an enlarged prostate. Other medications can reduce appetite and cause nutritional problems.

Often the dosing is different for younger people and older people. Seniors' kidneys might not dispose of medications as well as the kidneys of younger people, causing the medication to accumulate to dangerous levels.

Then there can be staff errors--for example, when nurses make mistakes administering medications. I would say, though, that the federal regulations are so tight for the long-term care industry that the error rate for mistakes of this kind is rather low.

How practical is the concept of an "ideal process" to address pharmaceutical issues universally throughout the long-term care continuum?

Dr. Dimant: We considered the various kinds of long-term care facilities. Basic concepts to address medication issues throughout the continuum are similar, but the systems to address them would be different for various settings, such as between nursing homes and assisted living facilities. What we mean by the "ideal process" is a process by which the physician prescribes appropriately, the pharmacist dispenses appropriately, the nurse administers appropriately and the medications are appropriately monitored for effectiveness and adverse reactions by all members of the team, including the consultant pharmacist.

Probably the most effective way to do this is through information technology. For example, there are systems that will warn pharmacists if there are any side effects with new medications and interactions with other medications that the residents are already taking. For example, if a resident is taking aspirin and a physician prescribes another blood thinner, the computer could give a warning of increased chances of bleeding. Also, if one doctor doesn't know what another doctor has prescribed, the pharmacist should have the resident's complete medication profile.

What are staff members' roles in improving medication management?

Dr. Dimant: First the medical director can help create and oversee the entire process. The director of nursing can help ensure that an appropriate process exists for medications to come into the nursing home and that they are distributed and administered appropriately. Next, the pharmacy provider ensures appropriate dispensing. The attending physician must be educated and informed and actively participating. Finally, the consultant pharmacist serves an important quality control function and can be indispensable in helping create, monitor and continually improve the process.

How big a factor has OBRA been in improving the situation?

Dr. Dimant: The literature suggests that it is has been an important factor, especially in improving the prescribing of psychoactive medications. We have seen a real reduction in the inappropriate use of antipsychotic medications. Another factor is that over time better medications can be and are developed that produce fewer adverse reactions.

What are the first steps facilities should take for change?

Dr. Dimant: They should study their processes for medication management and look for ways to improve them. This is an area where a medical director can help. The AMDA has done an excellent job in educating medical directors and long-term care physicians on the essentials of process improvement.

What are the future plans for the National Forum on Quality Pharmaceutical Care in Long Term Care?

Dr. Dimant: We came together to determine the major problems in the process, which was the first step. The next step is defining the appropriate process for each setting. There will be a "universal" process that applies to any facility and "subprocesses" for the various kinds of long-term care facilities, such as independent living, subacute care, assisted living, skilled nursing, etc. Once we define these processes, we will develop guidelines on implementing them in each setting. The AMDA has already developed effective guidelines for pain management and the treatment of pressure ulcers, for example, and I am confident we'll be able to do the same for pharmaceutical care processes.