Standard of Nursing Practice Protocol: Reducing Adverse Drug Events
DeAnne Zwicker, MS, APRN, BC, Terry Fulmer, Ph.D., R.N., FAAN
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.
The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
Assessment Tools and Strategies
Interventions and Nursing Care Strategies
Relevant Practice Guidelines
To proactively identify older adults at risk for adverse drug events (ADEs) and reduce the likelihood of it.
ADEs, whether from drug–drug or drug–disease interactions, inappropriate prescribing, poor adherence, or medication errors lead to serious or potentially fatal outcomes for older adults. Around 31% of all adverse events in hospitals are caused by medication-related problems. More than half of ADEs are potentially preventable. 1, 2, 3
- Adverse drug event: Injury occurring during the patient’s drug therapy, whether resulting from appropriate care or from unsuitable or suboptimum care. ADEs include adverse drug reactions (ADRs) during normal use of medicine and any harm secondary to a medication error. 4
- Iatrogenic ADEs: Any undesirable condition in a patient occurring as the result of treatment by a health care professional; pertaining to an illness or injury resulting from a medication.
- Adverse drug reaction: Any noxious or unintended and undesired effect of a drug that occurs at normal human doses for prophylaxis, diagnosis, or therapy.
- Drug–drug interactions: When one therapeutic agent alters either the concentration (pharmacokinetic interactions) or the biological effect of another agent (pharmacodynamic interactions). (Ref 1; 5)
- Medication adherence: The extent to which a person’s medication-taking behavior corresponds with agreed recommendations of a health care provider. (Ref 6)
- Drug–disease interactions: Undesired drug effects (exacerbation of a disease or condition by a drug) that occur in patients with certain disease states (e.g., beta blocker given to patient with bronchospasm).
- Pharmacokinetics: The time course of absorption, distribution across compartments, metabolism, and excretion of drugs in the body. The metabolism and excretion of many drugs decrease and the physiologic changes of aging require dosage adjustment for some drugs. (Ref 1)
- Pharmacodynamics: The response of the body to the drug that is affected by receptor binding, postreceptor effects, and chemical interactions. Pharmacodynamic problems occur when two drugs act at the same or interrelated receptor sites, resulting in additive, synergistic, or antagonistic effects. The effects of two or more drugs together can be either additive (combination of drugs “add up” to increase effect), synergistic (one agent magnifies the effect of the other), or antagonistic (one medication inhibits the effect of the other).
- Medication reconciliation: the process of comparing a patient’s medication orders to all of the medications that the person has been taking. 7
- It is estimated that the majority of older adults older than 65 years (79%) are on medications, with 39% taking five or more prescription drugs and up to 90% taking over-the-counter (OTC) drugs. 8 People older than 65 years consume more than one-third of all prescription drugs and purchase 40% of all OTC medicines. 9
- An estimated 35% of older persons experience ADEs and almost half of these are preventable. 3
- Prevalence of ADR-related hospitalizations ranges from 5% to 35%. (Ref 10; 11) Drug toxicity admission was 2.5% in the emergency department (ED) with 42% being admitted to the hospital for ADEs. (Ref 12)
- ADEs are estimated to cost the health care system $75 billion to $85 billion annually. 13
Adults become increasingly susceptible to ADEs as they age. Physiological changes characteristic of aging predispose older adults to experience ADEs resulting in four times more hospitalizations in older versus younger persons. People older than age 65 years experience medication-related problems for seven major reasons:
- Age-related physiologic changes that result in altered pharmacokinetics and pharmacodynamics. (Ref 2; 14) 2
- Multiple medications (i.e., polypharmacy) that are often prescribed by multiple providers. (Ref 2; 8; 15)
- Incorrect doses of medications (more than or less than a therapeutic dosage) (Ref 8; 16; 17) 16, 17
- Medication consumption for the treatment of symptoms that are not disease dependent or specific. (self-medication or prescribing cascades). (Ref 2; 18) 18
- Iatrogenic causes such as
- a. ADRs including drug–drug or drug–disease interactions. (Ref 10; 19; 20; 21) 20,21
- b. Inappropriate prescribing for older adults. (Ref 2; 13) 13
- c. Problems with medication adherence. (Ref 22; 23) 23
- d. Medication errors. (Ref 2; 9; 24)
Assessment Tools and Strategies
- Assessment Tools
- Use appropriate assessment tools as indicated for each individual's needs and specific setting:
- “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Part I: 2002 Criteria Independent of Diagnoses or Conditions.” “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Part II: 2002 Criteria Considering Diagnoses or Conditions”
- Try This Issue 16 - Beers' Criteria for Potentially Inappropriate Medication Use in the Elderly
- Part I
- Part II
- Common drug–drug interactions (see Table 17.1 in Protocols book). List of some commonly known interactions.
- Cockroft-Gault formula to estimate renal function (see Table 17.2 in Protocol book).
- Functional capacity (activity of daily living [ADL], independent activity of daily living [IADL], Mini-Cog, or Mini-Mental State Exam [MMSE]): assess ability to self-administer medications. (See Chapter 6, Assessment of Physical Function, and Chapter 8, Assessing Cognitive Function; or Resources section at http://www.consultgerirn.org/resources.).
- Brown bag method. (Ref 25) Method used to assess all medications an older adult has at home, including prescriptions from all providers, OTC medications, and herbal remedies (all medications are to be brought in a brown bag). Should be used in conjunction with a complete medication history (see Table 17.3 in Protocol book).
- Drugs Regimen Unassisted Grading Scale (DRUGS) tool. Assessment of self-administration ability. (Ref 26; 27)
- Assessment Strategies
- Comprehensive medication assessment should be performed at admission, discharge, and intervals in between. (Ref 20; 28) Obtain a detailed medication history and confirm its accuracy, (Ref 29) detailing the type and amount of prescriptions, OTCs, vitamins, supplements, and herbal remedies, (Ref 8; 30) 8; and alcohol and illicit drugs, using appropriate assessment tool (e.g., Brown Bag method). (Ref 25)
- Asses for medication- and patient-related risk factors for ADRs (Table 17.4).
- Assess renal function using Cockroft-Gault formula prior to administering renal-clearing drugs (see Figure 17.2 in protocol book).
- Reconciliation of medications from home or other levels of care with medications ordered at admission and at discharge in consultation with a pharmacist, geriatric expert, or computer-based program. (Ref 7; 31; 32; 33)
- Review medication list using Beers criteria for potentially inappropriate medications, particularly those with high severity and for potential drug–drug and drug–disease interactions. (Ref 2; 13; 34) 13
- At discharge from hospital, use appropriate tools to assess individual's ability to self-administer medications:
- Assess functional capacity: ADLs, IADLs, Mini-Cog. (See chapters in protocol book Assessment of Physical Function and Assessing Cognitive Function)
- Assess individuals (at admission or initial encounter and at discharge) who administer their own medicines with DRUGS tool to identify potential areas of self-administration difficulty (Ref 26; 27)
A. Reducing ADEs (during and post hospitalization)
1. Patient empowerment. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. If patients are involved in decision making, they are less likely to make decisions that may lead to ADRs, such as abruptly discontinuing a medication that should be tapered off. (Ref 35; 36)
2. Comprehensive medication history on admission as indicated in Table 17.3 in protocol book.
3. Collaborate with the interdisciplinary team to effect change in reducing the numbers of ADEs and ADRs, many of which are preventable. (Ref 8)
4. Prescribing principles. Although bedside nurses are not involved in prescribing, they are involved in reviewing and signing off medications, thus should be aware of prescribing principles. Monitoring for appropriate prescribing and alerting the prescriber to potential problem areas helps reduce medication-related problems. Prescribing a medication is multifaceted: deciding that a drug is truly indicated; choosing the best drug; determining appropriate dose for the individual; monitoring for toxicity and effectiveness; and seeking consultation when necessary. 2 These principles support recommendations to:
a. Reduce the dose. "Start Low and Go Slow," or give the lowest possible dose when starting a medication and slow upward titration to obtain clinical benefit; many ADEs are dose-related. (Ref 2; 20) 2 Primary provider should be notified if the dosage ordered is higher than the recommended starting dose (e.g., digoxin maximum dose, 0.125 mg for treatment of systolic heart failure). 13
b. Discontinue unnecessary therapy. Prescribers are often reluctant to stop medications, especially if they did not initiate the treatment. This practice increases the risk for an adverse event. 2
c. Attempt a trial of nonpharmacological interventions and treatments prior to requesting medication for new symptoms. 2
d. Recommend safer drugs. Avoid drugs that are likely to be associated with adverse outcomes (review Beers Criteria)
e. Assess renal function using Cockroft-Gault formula (for renally cleared drugs) to determine accurate dosage prior to prescribing such as many routinely prescribed intravenous (IV) antibiotics. Dosage recommendations are available based on this formula are presented in common prescribing resources.
f. Optimize drug regimen. When prescribing medications, the focus should be on risk versus benefit where the expected health benefit (e.g., relief of agitation in dementia with psychosis) exceeds the expected negative consequences (e.g., morbidity and mortality from falls that result in hip fracture) (Ref 2; 37; 38)
g. Initiation of new medication. Assess risk factors for ADRs, potential drug–disease and drug–drug interactions, and correct dosages. (Ref 20; 24; 35) See Table 17.1 and Table 17.4.
h. Avoid the prescribing cascade. Avoid the prescribing cascade by first considering any new symptom as being an adverse effect of a current medication prior to adding a new medication. (Ref 2; 39) 2
i. Avoid inappropriate medications. Review criteria for potential inappropriate medications, drug–disease interactions, and potential drug–drug interactions 13
j. Employ nonpharmacological approaches for symptoms (e.g., therapeutic activity kit for agitation) (Ref 40)
B. Specific interventions for prevention of iatrogenic ADRs (in hospital and after discharge)
1. Consider any new symptom as a possible ADR before requesting or administering new medication for the symptom, avoiding the prescribing cascade (Ref 10)
2. Monitor medication orders for wrong drug choices (high-risk inappropriate medications, drug–disease and drug–drug interactions), wrong dosages, or administration errors. (Ref 10; 24; 41) Consider use of technological handheld devices such as personal digital assistant (PDA) for quick access to Beers criteria, drug–drug or drug–disease interactions, and geriatric assessment tools (see www.ConsultGeriRN.org, Resources section, for drug interaction software/PDA tools).
3. Improve prescribing practices by documenting indication for initiation of new drug therapy, maintaining a current medication list, documenting response to therapy, as well as the need for ongoing treatment and evaluating comorbidities. (Ref 42)
4. Institutional implementation of computer-assisted technology for medication order entry: has the potential to prevent an estimated 84% of dose, frequency, and route errors. (Ref 43) Identifying and reporting ADRs can also be performed using computer-assisted national surveillance system.
5. Institutions must facilitate a culture of safety to reduce ADRs or ADEs. (Ref 9)
C. Interventions at Discharge
1. Reconciliation of medications at discharge helps to reduce ADR or ADEs and rehospitalization. (Ref 31; 44)
2. Assess abilities and limitations and health literacy in self-administration of medications using appropriate tools at discharge and recognize that self-administration and nonadherence can induce ADRs. (Ref 42; 45)
3. Assess for adherence issues that may develop after discharge, which can help to reduce ADEs and rehospitalization. (Ref 27; 44; 46; 47) Recommend devices that can assist in enhancing adherence, behavior, and interventions to address cost and other adherence issues.
4. Patient/Caregiver education. Provide patient and caregiver education using relevant nursing content and principles including assessment of factors that might affect adherence. Nurses are the primary source for providing education to patients at discharge; therefore, their role is key to preventing medication-related consequences after hospitalization. (Ref 45) Discharge education and counseling includes the following:
a. Education tailored to the age group and needs of the individual. (Ref 45)
b. Educate the patient and caregiver about benefits and risks and potential medication side effects. (Ref 2; 28) 2
c. Teach safe medication management; use teach-back as a methodology. (Ref 45; 48)
d. Consider an interactive computer program (personal education program) designed for the learning styles and psychomotor skills of older adults to teach about potential drug interactions that can result from self-medication with OTC agents and alcohol. (Ref 49)
A. Patients will:
1. Experience fewer iatrogenic outcomes from medication-related events.
2. Demonstrate understanding of their medication regimens upon discharge from the hospital.
B. Healthcare providers will:
1. Use a range of interventions to prevent, alleviate, or ameliorate medication problems with older adults.
2. Improve prescribing practices by documenting indication for initiation of new drug therapy, maintaining a current medication list, and documenting response to therapy as well as the need for ongoing treatment.
3. Evaluate nature and origins of medication-related problems in a timely manner.
4. Increase their knowledge about medication safety in older adults.
5. Increase referrals to appropriate practitioners for collaboration and medication safety (e.g., pharmacist, geriatrician, geriatric/gerontological or psychiatric clinical nurse specialist, nurse practitioner, or consultation-liaison service).
C. Institution will:
1. Provide a culture of safety that encourages safe medication. (Ref 9)
2. Provide education to health care providers regarding prevention, identification, and reporting of ADRs. (Ref 50)
3. Make information on ADRs accessible to patients. (Ref 50)
4. Enhance surveillance and reporting of ADRs using a national surveillance system. (Ref 50) Consider use of computerized physician order entry system. (Ref 50; 51)
5. Track and report decreased morbidity and mortality caused by medication-related problems.
6. Provide a system for medication reconciliation and follow-up its effectiveness regarding rehospitalization rates caused by ADRs.
7. Review for careful documentation of iatrogenic medication and other iatrogenic events for continuous quality improvement (CQI).
8. Provide ongoing education related to safe medication management for physicians, other licensed independent providers, pharmacists, and nursing staff.
A. Health care providers will:
1. Provide consistent and appropriate care and follow-up in presence of a medication-related problem.
2. Monitor and evaluate with physical exam and/or laboratory tests (as appropriate) on regular basis to ensure that the older adult is responding to therapy as expected. (Ref 27)
B. Institutions will:
1. Provide ongoing assessment of staff competence in assessing and intervening for prevention of ADEs.
2. Embed reduction of ADEs in the institution's culture of safety.
Relevant Practice Guidelines
A. Bergman-Evans, B. (2004). Improving medication management for older adult clients (NGC Guideline No. 003993). Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core. Retrieved from www.guideline.gov
B. Health Care Association of New Jersey. (2006). Medication management guideline. Hamilton, NJ: Author. Retrieved from www.guideline.gov. Note: Geared for post-hospital institutions for adult patients. NGC Guideline # 004951
For Definition of Levels of Quantitative Evidence Click Here
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
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Last updated - September 2012