Author: Nick Zamora
Better Medication Management Series: Part 2 of 4
Systemic Issues Are Leading to Medication Error, Adverse Drug Events and Worse Patient Outcomes.
Approximately 119 million Americans aged 12 and older use prescription drugs to treat various chronic and temporary medical conditions. Such widespread usage has led to an unnecessary number of medication errors, which can occur at any phase of the medication use process, such as during prescribing, transcribing, dispensing, administration, adherence and/or monitoring.
A medication error can lead to patients taking unnecessary drugs, the wrong drug for their condition or the right drugs in the wrong dose. The personal and economic costs associated with this are steep, impacting patients, physicians, other Providers and healthcare systems. Consider the following:
- Preventable medication errors impact over seven million patients in the US and cost almost $21 billion annually across all care settings;
- Adverse drug events (ADEs) resulting from medication errors account for more than 3.5 million physician office visits yearly;
- ADEs account for one million emergency department visits and 125,000 hospital admissions yearly.
Medication error is the by-product of a fragmented approach to medication management, whereby:
- Pharmacists can’t access patients’ medication history, yet their role has expanded beyond dispensing medication;
- Healthcare practitioners lack clarity on their roles and responsibilities;
- There’s a lack of communication and collaboration among primary care Providers, hospital doctors, specialists, pharmacists and nurses.
Three main obstacles to an evidence-based approach to medication management can be identified:
1. Shifting Role of Pharmacists
Responsibility for medication management has evolved over the years, with pharmacists playing their most significant role yet. While this shift should be accompanied by greater collaboration, there is often a lack of coordination among other healthcare Providers and pharmacists. Pharmacists should also have access to patients’ discharge records, which would allow them to reconcile discharge medications with pharmacy medication lists. However, pharmacists currently do not have access to the information needed for active medication management. The unfortunate outcome is a higher than necessary incidence of medication error for patients. This situation is exacerbated by other factors, including:
- More orders: pharmacists are handling a greater number of orders during their shifts, leading to more errors. One study at a tertiary care medical center concluded the overall error rate was 4.87 errors per 100,000 verified orders.
- Increase in polypharmacy: the number of older adults in the US taking more than five medications has been steadily rising. When more than one Provider prescribes medication to a patient, inappropriate prescribing is more likely to occur.
- Insufficient MTM: pharmacists’ role has expanded beyond distribution to include medication therapy management (MTM), which involves educating patients on their medications and optimizing therapy by improving adherence and detecting potential ADEs. In the US, about 65% of Medicare Part D plans now offer MTM delivery through community pharmacists. However, a pharmacist’s ability to provide proper MTM is compromised by a lack of communication between pharmacists and other care Providers. Increasing polypharmacy further complicates this situation.
2. Failure of Medication Reconciliation During Care Transitions
Medication reconciliation is a process where healthcare Providers work together to ensure accurate medication information is consistently communicated across transitions of care. It requires a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully evaluated. Reconciliation is a component of medication management that enables prescribers to make the most appropriate decisions for patients.
However, despite the importance of medication reconciliation during care transitions, discrepancies often occur. An issue is the absence of a standardized process for obtaining and documenting a complete and accurate list of a patient’s current medications. Comparing this list with medication orders at each point of care transition to identify and resolve any discrepancies is also currently non-existent. Consequently, about 30% of hospitalized patients have at least one medication discrepancy upon discharge.
The lack of standardized procedures governing medication reconciliation has impeded coordination and communication among healthcare professionals, while simultaneously preventing a clear delineation of responsibilities. In an ideal scenario, medication reconciliation should be a coordinated effort among healthcare professionals during each transition of care, leading to active medication management.
3. Confusion about Roles And Responsibilities
Medication reconciliation is often regarded as an administrative task, rather than a vital safety-promoting one, leading to a lack of clarity and consensus as to who is responsible for it. Several studies have been conducted examining the consequences of this problem. In one study, home care nurses reported that formal responsibility for medications after a patient is discharged from hospital resides with the primary care provider. However, primary care Providers may be reluctant to take responsibility for medications prescribed by hospital doctors. Meanwhile, hospital doctors may be reluctant to take responsibility for medication following discharge. The result was that the nurses ended up taking responsibility for patients’ medications.
In another study, pharmacists reported challenges related to a lack of clarity around roles and responsibilities and difficulties communicating across organizations. These challenges were amplified by a lack of access to patients’ electronic medical records. Pharmacists who tried to confirm medication information after a patient was discharged often had trouble connecting with hospital doctors or were referred to the patient’s primary care physician, who often wasn’t even aware that the patient was in hospital.
Further complicating the situation is the fact that many Americans see multiple Providers. Older adults with five or more chronic conditions have an average of 50 prescriptions filled and see 14 different physicians.
This means medical information is often changing hands at multiple points during a patient’s healthcare journey, creating a lot of potential for errors if the right communication systems aren’t in place. Considering four out of every 10 adults in the US have two or more chronic conditions, it’s easy to see why ADEs occur with alarming frequency.
Overcoming Obstacles to Evidence-Based Medication Management
In an increasingly prescription dependent population, medication error is not–and should not–be a foregone conclusion. Indeed, Americans’ growing reliance on prescription medications reinforces the need for a collaborative, evidence-based approach to medication management whereby physicians, pharmacists and patients work together to ensure safe, effective and appropriate drug therapy. Such an approach requires a coordinated and monitored effort to ensure the right drug is being taken at the right time and in the right dose to achieve optimal patient-centered healthcare.
The barriers to evidence-based medication management provide a strong argument in favor of easy data collection and exchange through interoperable systems. An interoperable network would provide all doctors, nurses and pharmacists involved in a patient’s care access to medication lists both in their own patient record systems and in remote systems. The lists would need to be reconciled before the systems could be used safely and any clinical risks may be associated with a failure to reconcile lists. Interoperable systems could also be designed to support the accurate reconciliation of medication lists, helping ensure safe treatment for patients and reducing incidences of ADEs.
Smile with HealthChain
It’s possible to develop a health information exchange focused on addressing the data gaps in drug information, as demonstrated by the company HealthChain Inc. Built on the Smile CDR data platform, the system empowers all healthcare practitioners involved in a patient’s care to make informed medication management decisions around prescribing and medication reconciliation. Clinicians in hospitals and community based Providers can also easily review a patient’s current and previous medications during transitions of care. By de-siloing information, promoting collaboration and arming Providers with vital medication data about patients, there will be less incidents of medication errors, fewer ADEs and better patient outcomes.
To continue learning about Better Medication Management, read our blog series.Part 1: Striving for Better Medication Management
Part 2: The Barriers to Evidence-Based Medication Management
Part 3: Achieving Drug Data Interoperability with FHIR
Part 4: Practical IT Steps for Drug Management (Coming Soon)
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