Higher risk of medication errors for seniors: Home health bigger challenge

Use guidelines specific to elderly, and monitor errors

Each year, more than 200,000 people die and another 2.2 million people are injured due to medication-related problems.1 Because seniors between the ages of 60 and 65 fill an average of 13.6 prescriptions per year, and that number increases with age, seniors are more susceptible to medication-related problems.2

The challenge for home health agencies has been the lack of a systematic approach to monitoring and reviewing medications taken by home health patients, says Dennee Frey, Pharm D, project director for the Partners in Care Foundation, a Los Angeles-based, nonprofit organization that helps health care providers create new ways of delivering care. "Medication-related problems for home health patients include a greater risk of falls, confusion, incontinence, and psychiatric problems," she points out.

Frey headed up a research project that took a look at how medication could be better managed for home health patients.

"We started by reviewing the charts of 6,700 patients and discovered that between 19% and 30% had a potential problem with their medications," she says. Because the physiological changes that occur as a person ages can affect how medications are metabolized and medications can cause side effects in a senior that don’t occur in a younger person, it is important to have medications reviewed by knowledgeable clinicians, she says.

After identifying the types of problems that can occur, Frey designed a randomized control trial that included agencies using an intervention program that incorporates the use of medication guidelines and access to a consultant pharmacist for home health clinicians. "Medication use improved in 50% of the intervention patients as compared to 38% of the control group patients," Frey says.

Because medication management skills vary among home health clinicians, the intervention project developed guideline software that enables the clinician to input the complete list of medications used by the patient. The software flags medications that may interact or create an unwanted side effect and alerts the consulting pharmacist. The nurse and pharmacist discuss the medications and alternatives, and then the nurse contacts the patient’s physician to suggest changes if needed, Frey says.

"Our nurses see the guidelines and access to a pharmacist as a great resource that can improve their clinical skills," says Joan M. Marren, RN, chief operating officer of the Visiting Nurse Service of New York in New York City, a participant in the pilot project. "Home health nurses don’t have easy access to the patient’s physician, and the patient may have multiple physicians prescribing medications. Also, our long-term home health patients average eight medications per patient, so it is difficult to monitor potential side effects," she adds.

"We used to rely upon our drug reference book but it doesn’t always tailor side effects to the elderly," Marren says. By using the pen-tablet computer and software that are tailored to identify problems specific to elderly people, nurses can identify potential problems, she says. "The book is still used for extra reference, but the nurses like the software and the pharmacist backup."

Medication is one of the first areas that should be reviewed carefully if your patient experiences a fall, Frey says. "Mrs. Jones may be on several blood pressure medications that contributed to her fall." Often, a review of medications will identify duplicate medications, she adds. "The patient may have a generic and a brand name of the same drug and be taking both without realizing it," she says.

Patient education may be all that is needed in some cases, Frey points out. The physician may have never intended the patient to take two blood pressure medications, but the patient may not have realized that a new prescription was to be used in place of a previous prescription, she says.

"In our chart review, we discovered a lot of older patients taking benzodiazepine for anxiety or insomnia," Frey says. These patients were at a higher risk for falls and to develop confusion than patient not on these drugs, she adds. All psychotropic drugs increase a patient’s risk for confusion and falls, she adds.

Even if the patient’s physician changes the medications or decreases the dosage, you have to be sure to educate the patient as to the reasons for changes, Frey says. Not all patients understand that fewer medications may be better for them, she says. "In the case of psychotropic medications, the patient may have become habituated and may not want to give up the drug."

Medication errors also exist when the medication is given by IV pump, according to Barbara Rosenblum, president of Strategic Healthcare Programs in Santa Barbara, CA, a health care benchmarking firm. Her company has looked at IV medication errors and the reasons for those errors.

Using data from more than 300 home health agencies that use the same software, Rosenblum found a total of 1,154 IV medication errors between Jan. 1, 1999, and Dec. 31, 2001. (See the statistical breakdown, below.)

Of these errors, 24% were related to pump programming errors, Rosenblum says. The reasons for medication errors due to pump programming errors ranged from wrong dosages or frequencies to wrong durations. Wrong dosage was cited as the reason for medication error when pump programming errors were involved most often 113 times or 41% of the total, during the three-year period, she says. This is significantly higher than the wrong dosage category for IV medication errors that were not due to pump programming errors, Rosenblum says. Out of 877 IV medication errors not due to pump programming errors, 222 or 25% of the total were due to wrong dosage, she says.

Although the problem has been identified through the benchmarking information, the solutions to the problems may differ from agency to agency, she adds.

"We’ve heard from our clients that a variety of approaches have to be taken to address the problem of pump programming errors," Rosenblum says.

Some of the solutions include:

• Evaluate the IV pump.

Some pumps are less complicated to program, she says. Consider having more than one pump available to enable a choice that can be made on a case-by-case basis depending on the nursing experience, complexity of programming, patient location, and competence of family members, she suggests.

• Provide quarterly training updates.

Don’t rely on a once-a-year review of the clinicians’ pump programming knowledge, Rosenblum advises. Training sessions should occur quarterly and focus on dosage, frequency, and rate, she says.

• Designate specific nurses to program pumps.

If you limit pump programming to a select group of nurses, you can make sure more easily that each nurse is trained and up to date on each pump, Rosenblum says.

Most importantly, make sure you create an environment that fosters reporting of medication errors, she says. "Historically, error reporting has been punitive, but we have to make sure that employees feel comfortable reporting errors so our processes can be reviewed . . . to prevent further errors," she points out.

Now, all health care agencies are realizing that it is difficult to protect patient safety when employees are afraid of reporting errors, Rosenblum adds.

Frey’s organization has developed a tool for home health agencies to help them avoid medication errors. "We used the information and experience from our trial studies to develop a series of free web-based tools that home health agencies can use to better manage their patients’ medications," she says.

The web site (www.homemeds.org), scheduled for launch at the end of July, as we go to press, offers guidelines, drug protocols, cost/benefit information, and technical assistance, she says.

Frey also plans to include monthly chat sessions and miniseminars through the site to provide ongoing assistance and information exchange among participants.

Both Frey and Rosenblum explain that addressing the issue of medication errors is not a simple task, but benchmarking, reviewing practices, and using available tools to improve management of medications will improve patient safety.

[For more information about medication management programs and benchmarking, contact:

  • Joan M. Marren, RN, Chief Operating Officer, Visiting Nurse Service of New York, 107 E. 70th St., New York, NY 10021. Telephone: (212) 794-6311. E-mail: jm@vnsy.org.
  • Dennee Frey, Pharm D, Project Director, Partners in Care Foundation, 101 S. First St., Suite 1000, Burbank, CA 91502. Telephone: (818) 526-178, ext. 180. E-mail: dfrey@picf.org.
  • Barbara Rosenblum, President and CEO, Strategic HealthCare Programs, 222 E. Canon Perdido S., Suite 304, Santa Barbara, CA 93101-2283. Telephone: (805) 963-9446. Fax: (805) 963-2102. E-mail: brosenblum@shpdata.com.]

References

1. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: Updating the cost-of-illness model. J Am Pharm Assoc 2001; 41:192-199.

2. American Association of Retired Persons. Issue brief. Washington DC; 1991.

IVs and Medication Errors

Dosage and frequency most common errors for IV drugs

The total number of IV medication errors reported by more than 300 home health agencies in a three-year study conducted by Santa Barbara, CA-based Strategic HealthCare Programs was 1,154. In both categories of errors due to pump programming errors and errors not due to pump programming errors, wrong dosage and wrong frequency were the most common errors.

Total number of med errors from Jan. 1, 1999 to Dec. 31, 2001: 1,154
The number of all IV medication errors not due to pump programming: 877 (76%)
The number of all IV medication errors due to pump programming errors: 277 (24%)

Reasons for errors not due to pump programming

(Editor’s note: Categories for types of medication errors changed in 2000, so some of the categories in 1999 were not collected after 2000 and vice versa.)

Medication given to wrong patient 6 (0.7%)
Other 105 (12%)
Wrong dosage 222 (25%)
Wrong dosage; wrong frequency 7 (0.8%)
Wrong duration 42 (4.8%)
Wrong frequency 224 (25.5%)
Wrong medication 75 (8.5%)
Wrong preparation of dose 162 (18.5%)
Wrong rate 21 (2.4%)
Wrong route 11 (1.3%)
Wrong route; wrong frequency 2 (0.2%)

Total 877

Reasons for errors due to pump programming

Other 11 (4%)
Wrong dosage 113 (41%)
Wrong dosage; wrong frequency 6 (2.2%)
Wrong dosage; wrong rate 3 (1%)
Wrong duration 25 (9%)
Wrong frequency 72 (26%)
Wrong preparation of dose 9 (3.2%)
Wrong rate 38 (13.7%)

Total 277