How to do it ... better med management
1. Acknowledge the challenges. Adverse drug events are the leading cause of rehospitalizations, according to Frank Grosso, R.Ph., executive director and CEO of the American Society of Consultant Pharmacists.
Medication administration is complicated by residents' advanced age, multiple chronic conditions and unpredictable drug response. Worse, polypharmacy causes a nearly endless cycle of meds prescribed to treat the effects of other meds. Without residents' own feedback, “we rely on nurses to see these changes for what they are — medication-related and not disease-related — a difficult and daunting task.”
T.J. Griffin, R.Ph., chief pharmacy officer for PharMerica, strongly advocates root cause analysis.
“When you focus on coagulation, hyperglycemia, COPD, fall prevention — all have ADE consequences or possible root causes,” he says. “Nursing homes are addressing med management issues. I don't think they know that they're actually addressing adverse drug events.”
Other root causes can be inappropriate prescribing/dosing, inadequate med monitoring, substandard treatment and failure or delay in necessary care, adds Doris Yee, Pharm.D., a clinical pharmacist in the Consumer Drug Information Group at First Databank.
2. Handoffs can cause problems, experts warn. “Many adverse drug events originate and manifest due to the lack of comprehensive medication review during these transitions,” Grosso notes.
Griffin advises thorough medication reconciliation before or immediately after a resident arrives from another place or is transferred.
“This is where drugs are omitted or improperly transcribed in terms of name or dosage,” he says.
3. All too often caregiver and resident family members will never consider the serious interaction over-the-counter meds like aspirin and supplements like St. John's Wort could inflict on residents with powerful prescription drugs, adds Griffin.
They all should be a part of the resident's medication profile — all the better if it's electronic so it can be easily shared with pharmacists and physicians. “Mis-medication” occurs even with OTC drugs, adds Laya Klein, quality control director of Geri-Care Pharmaceuticals.
4. Engage your consultant pharmacist on all med management issues. Grosso encourages a “48-hour admission protocol established as a collaboration between the nursing staff and the consultant pharmacist that includes risk assessment, full pain assessment and reconciliation of all current and historical medications to current diagnosis and patient condition to establish patient need.”
Consultant pharmacists can mitigate or even eliminate polypharmacy issues.
“If we change the patient's first drug to something that doesn't have side effects, you might able to get rid of drug 2 and drug 3,” Griffin adds.
Tap into the Institute for Safe Medication Practices, which offers self-assessment tools for homes to evaluate their medication practices, says Jayne Warwick, RN, PointClickCare's skilled nursing segment marketing manager.
5. Have your house in order. Warwick advises efforts like closed-loop electronic medication systems, specific clinical practice guidelines or policies for the administration and monitoring of high-risk drugs or high-risk residents, quality assurance/performance improvement teams and staff education and training.
Reduce therapeutic intervention delays, monitor multiple care providers and enhance ADE surveillance and reporting systems, suggests Yee.
6. Invest in an EHR. There are acknowledged barriers like cost and interoperability, but a quality platform that seamlessly “talks” with other systems “is the most efficient means of achieving success,” says Grosso.