Preventing Medication Errors

More than 1.5 million Americans are injured every year by drug errors in various settings, including nursing homes. The Institute of Medicine (IOM), in its most recent report, evaluated medication errors in a broad range of settings, and finding tremendous room for improvement.¹ In the report, the IOM states that at least one-quarter of all medication-related injuries are preventable. Gurwitz et al^2,3 estimated that 800,000 preventable medication-related injuries occur annually in nursing homes across the country.

Most of the “medication errors” in long-term care (LTC) settings, as reported in the IOM report, are related to prescribing and monitoring of medications. However, in the definition used for the nursing home survey process, errors related to prescribing are not considered medication errors. As a result, we end up with varying definitions of what qualify as medication errors. We should consider broadening the LTC definition to include the scope that the IOM and others consider it to be—that is, errors related to prescribing, administering, and monitoring of medications. Medicare Part D creates opportunities and challenges in working to reduce the number of medication-related errors, especially in the LTC setting.

BEERS CRITERIA

An opportunity for such an improvement exists with the use of the Beers Criteria. In 1997, the noted geriatrician Dr. Mark Beers developed and published the Beers Criteria.⁴ This outlined explicit criteria for use in prescribing medications for older patients, and identified several commonly used drugs that should be considered potentially inappropriate for use in the elderly. The Centers for Medicare & Medicaid Services adopted the criteria as part of the nursing home regulations. More recently, the criteria has been revised to take into account information available since the original publication.⁵

The Medicare prescription drug benefit offers an opportunity for incorporation of the Beers Criteria into the development of formularies and utilization measures to further ensure appropriate prescribing for older patients. Unfortunately, few prescription drug plans to date have utilized the Beers Criteria explicitly in either their formulary design or utilization management tools. Still, a great opportunity exists for incorporating these criteria to ensure more appropriate use of medications in the elderly.

TRANSITIONS IN CARE

One major area where medication errors occur in LTC is during the transitions from one care setting to another.^6-9 The transitions from the nursing home to other settings are times of high risk for adverse effects due to prescribing or transcription errors. Excluding wrong-time errors, omission of an ordered medication is generally the most common type of drug administration error in nursing homes.

In this instance, Medicare Part D only serves to add to the confusion since transition in settings of care may mean transitions in prescription drug coverage administration. With this change in coverage, medications are often required to be changed from a nonformulary medication to one covered under the plan.

MED PASSES

Another area in the nursing home where medication errors occur is during the medication administration, or “med pass.” Since a typical medication pass in LTC usually exceeds 2 hours, it may be impossible for a nurse to deliver all medications within 1 hour of the scheduled time, making “wrong-time” errors predictably high in this setting.

Medicare Part D makes this situation increasingly more likely because prescription drug plans often restrict access to extended-release medications, while forcing the use of short-acting ones. This can result in more medications being administered during each med pass, with the likelihood of a delay in medication administration increasing. Nursing homes can minimize this potential error if they can successfully persuade prescription drug plans of the importance of extended-release medications for LTC residents to help alleviate this problem.

THE FIX

A method to ensure improvements in the area of transition of care is by providing a continuum to the medical record. By providing an electronic medical record that would be utilized through the continuum, rather than the alternative paper charts that are often fragmented, transition of care would likely not be as significant an issue as it is today. Since Medicare managed care plans are responsible for the full continuum of care, development of a uniform electronic record within a managed care system provides a great opportunity to reduce costs and medical errors.

Another opportunity for improved outcomes is available through the use of computerized physician order entry (CPOE) with clinical decision support, which has had few implementations outside of the acute hospital setting. Use of this technology in nursing homes would provide many opportunities to prevent medication errors and adverse drug events (ADEs). This fact was not lost on the IOM recommendations, which stated that all prescriptions should be written electronically by 2010, including those in LTC.

Since its beginning, the Medicare Modernization Act set out the requirement for prescription plans to perform medication therapy management services (MTMSs) to improve medication outcomes. While MTMS can provide great opportunities for improving medication management, it must first deal with working within the current drug regimen review (DRR) structure already in place in LTC. With DRR, consultant pharmacists are required by the facility to conduct federally mandated DRR services. This provides comprehensive assessment of the drug regimen of a resident, which includes preventing, identifying, and resolving medication-related problems and medication errors, and collaborating with the interdisciplinary team to promote positive outcomes of drug therapy. While in many ways MTMS is a duplication to the DRR, it may provide additional resources and data to enhance the current DRR system already in place.

SUMMARY

In the end, Medicare Part D can provide great opportunities to improve medication management for LTC residents—but only after clinicians and policymakers overcome significant challenges that may actually result in increased medication errors. Hopefully, we can improve upon the findings of the IOM and improve care to our older residents. By taking advantage of opportunities such as utilization of the Beers Criteria, improving transitions in care, ensuring access to extended-release medications, and strengthening drug regimen review through medication therapy management services, we can make a positive impact on care of the elderly. Prescribers are faced with increasingly complicated medication regimens, so now is certainly the time to act.

Please send any questions or experiences about Medicare Part D you would like to share with readers to: BSpivack@Waveny.org