An Ounce of Prevention

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Prescription for Medication Safety

by Miranda Felde, MHA, BSHCS, CPHRM, ARM, CRM, CIC, Regional Patient Safety/Risk Manager, and Howard Marcus, MD, FACP, Chair, Texas Alliance for Patient Access, and Chairman, The Doctors Company Texas Physician Advisory Board

^{Robin Diamond, MSN, JD, RN}

This quarter Miranda Felde and Howard Marcus, MD, FACP, discuss challenges in ensuring safe medication practices and outline components for reducing the risk of adverse drug events.

—Robin Diamond, MSN, JD, RN; AHA Fellow–Patient Safety Leadership; Senior Vice President, Department of Patient Safety

Introduction
Most health care professionals are familiar with To Err Is Human: Building a Safer Health System, the Institute of Medicine’s (IOM’s) report published in 1999. In a follow-up study focusing specifically on medication errors, the IOM reported that at least 1.5 million preventable adverse drug events (ADEs) occur in the United States each year.¹ Moreover, these adverse drug events financially impact the health care industry with conservative estimates ranging upward of $3.5 billion a year, not including costs associated with lost earnings or compensation for pain and suffering.² Because physicians prescribe numerous medications on a daily basis, appropriate prescribing processes and systems that ensure safe medication practices are vitally important.

Challenges Physicians Face
Prescribing medications can be challenging to physicians, and they must consider multiple factors that include patient populations, patients’ diseases and conditions, and patients’ compliance with medical plans of treatment. In some instances, physicians also face prescribing challenges in acute care facilities, skilled nursing facilities, ambulatory surgery centers, and ambulatory care clinics.

Generally, acute care facilities and long-term care facilities have established clearly written prescribing guidelines for all medical staff, and many health care organizations are implementing electronic processes and systems to reduce the incidence rate of medication errors. Written prescribing guidelines and electronic prescribing and dispensing processes and systems are, unfortunately, not common in physician office practices.

Potential Risks
In the previous article, “Dilaudid-Related Morbidity and Mortality from Respiratory Depression,” Howard Marcus, MD, FACP, reported that “the accidental overdose of opioids has increased over the past decade.”³ Certainly opioids and narcotics are medications that tend to have an increase of risk for an adverse drug event to occur, but other controlled substances and nonscheduled medications are equally as lethal given certain dosages and drug interactions.

These medications are prescribed by many physician specialties. For example, one study found that general practice/family medicine, internal medicine, psychiatry, anesthesiology, emergency medicine, and general surgery physicians are among the most prevalent specialists prescribing opioids.⁴ It is interesting to note that both pain medicine and rehabilitation physicians were among the more infrequent specialists prescribing opioids.⁵

Physicians prescribing opiates must appreciate the potential for drug interactions given the variation in patient absorption, metabolism, elimination, or distribution of any drug.⁶ Patients who are opiate-naïve must be identified and educated concerning the reactions, side effects, and symptoms that may occur when taking an opiate. Moreover, patients who are currently taking other medications or consuming alcohol or drugs are at greater risk for enhanced or increased opiate effect. Physicians must also consider patients who have comorbidities that impact the effects of opiates. These types of patients may include those of advanced age or those with respiratory depression or prolonged opiate use, i.e., functional dependence.

Patient Safety Recommendations
Creating safe medication prescribing processes and systems is a critical component in reducing the risk of adverse drug events and medication errors. For physicians working in an ambulatory clinical delivery setting and prescribing controlled substances and nonscheduled medications, important aspects of prescribing processes⁷ include the following:

• Conducting a thorough examination of the patient prior to prescribing medications or renewing prescriptions, especially for an opioid medication.
• Obtaining a medication history on the initial visit, entering it onto a medication log or form, and placing it in the patient’s medical chart. Include prescription medications, over-the-counter medications, alcohol and drug use, vitamins, herbal products, dietary supplements, alternative medicine, and homeopathic medications.
• Updating the medication history/medication log at each patient visit.
• Providing the patient with an up-to-date list of medications at the end of each encounter.
• Informing the pharmacy about the patient’s comorbid conditions, allergies, weight, and date of birth when calling in the prescription orders. Spell out drugs with similar sounding names. Determine when your prescription should include the indication for the medication, such as when ordering sound-alike medications, PRN medications, and high-risk medications, and apply consistently.
• Preparing a prescription label for sample medications for the patient to take home. The label must meet state pharmacy regulations.
• Providing medication counseling to the patient or caregiver with consideration given to any language or literacy barrier and to any hearing or sight impairment of the patient or caregiver. Use the Ask Me 3⁸ guidelines or “teach-back”⁹ method to ensure patient understanding.
• Obtaining and documenting informed consent.
• Monitoring medication usage closely, particularly for controlled substances.
• Not storing drugs (sample medications or clinic medications) that look alike or sound alike adjacent to each other.
• Documenting all medications administered to the patient during the clinic visit, including vaccines and sample medications.
• Asking the patient about medication allergies or sensitivities to substances at each visit or at least yearly, and documenting the information on the medication log for easy access.
• Providing education to the patient on his or her medications and on any potential interactions, such as with herbal and nutritional substances. Also include signs and symptoms of untoward reactions with medications and provide instructions on whom to call for further care.

Conclusion
Adverse drug events occur regularly in all types of health care delivery models. In situations involving narcotics and opioids, the incidence rate is greater. Establishing and adhering to written processes for prescribing any type of medication will reduce the risk of an adverse drug event or medication error.

For more information on safe medication prescribing practices, please contact the Department of Patient Safety at The Doctors Company at (800) 421-2368, extension 1243.

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