Strategies to Improve Medication Safety and Reduce Harm in Polypharmacy

Celina B
Polypharmacy

In our previous blog, we discussed high-risk situations arising from look-alike, sound-alike (LASA) medications and high-alert medications which can cause significant medication harm. In this blog, we will talk about how to improve medication safety and adopt strategies to reduce polypharmacy, a term that refers to the use of multiple medications at the same time by one person.


Medicines can provide many benefits in treating and preventing health problems. However, at times polypharmacy can be inappropriate.
For example, people may still be taking medicines that are not working or no longer needed; medicines may have been prescribed to treat the side effects of other medicines or other treatment options which might lead to severe side effects or harm. Elderly people with multiple chronic diseases are the most vulnerable group in polypharmacy.

Statistics on Impact of Polypharmacy

Inappropriate polypharmacy is one of the most significant public health issues facing us today, especially amongst the elderly. Polypharmacy increases medication safety risk due to the likelihood of side effects, risk of interactions between medications and making medicine adherence more difficult. This challenge is set to increase as the population ages (in some countries) and more people suffer from multiple chronic diseases. 

 

The depth and breadth of polypharmacy’s impact on are highlighted in the following statistics:

50% of hospital admissions due to Adverse Drug Events (ADEs) are preventable. 70% of these are inpatients over 65 years of age and on 5 or more medicines.

67% of elder people are taking five or more prescription drugs, over-the-counter medications, and supplements

Polypharmacy increases the risk of ADEs, from 13%, which is associated with taking two medications, to 58%, which is associated with five drugs

8.6 million unplanned hospital admissions were caused by ADEs in Europe every year. 70% of these inpatients are over 65 years of age.

Risks and Challenges due to Polypharmacy

In general, the issue of polypharmacy mainly revolves around the elderly (65 years of age and above). Let us review some of the commonly discussed challenges, including adverse effects, medication adherence issues, and most recently the impacts of the COVID-19 pandemic.

    • ● More medication means a more complex dose schedule as well. Even if patients use a calendar to schedule dose intake, they may still experience occasional poor compliance or confusion with multiple doses.

    • Side effects associated with polypharmacy can create issues with adherence compliance. If a patient is taking medication that causes fatigue, they could sleep through the dosing period. Also, some medications may even cause memory loss in patients leading to double dosing (overdose).

    • Prescribers have tools that can help predict possible adverse drug reactions between medications, they often don’t make up for the fact that polypharmacy raises the risk that medications taken together will lead to potentially harmful interactions.

    • Some medications come with lengthy instructions that spell out the amount of medicine to take, how to take it, frequency of intake, and when not to take the drug so patients have the potential for getting confused due to such LASA drugs.

    • COVID-19 pandemic has taken a significant toll on people, which has translated to substantial increases in medication use. For instance, consumer use of antidepressant, anti-anxiety, and anti-insomnia medications increased the risk of medication errors due to polypharmacy.

Strategies and Tools to Reduce Polypharmacy

The healthcare industry has made significant collective efforts to develop tools that can help tackle the challenges inherent to polypharmacy. The following are some of the strategies and tools your organization can adopt to reduce polypharmacy, increase deprescribing, and help patients achieve substantial clinical and financial benefits.

1. Deprescribing

Deprescribing is considered one of the most effective ways to decrease polypharmacy. It is the planned and systematic process of identifying and reducing or discontinuing medications that may no longer be of benefit or may be causing harm. The main goal is to reduce the potential adverse effects of polypharmacy. This is achieved by multidisciplinary team collaboration and addressing the patient’s current needs and goals of care.

2. MAI Index

The Medication Appropriateness Index (MAI) is a set of 10 questions conceived to help clinicians make deprescribing decisions. Each criterion is rated on a three-point Likert scale. When added up, the resulting score is intended to determine the level of inappropriateness, with a score of 0, meaning the drug is appropriate, and 18 representing maximal inappropriateness.

3. Beers Criteria

The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beers List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older in all except palliative settings. The Beers Criteria are intended to serve as a guide for clinicians and the criteria may be used in conjunction with other information to guide clinicians about safe prescribing in older adults.

4. STOPP/START Criteria

These two resources — the screening tool of older people’s prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria — were first published in 2008 and most recently updated in 2014. The latest versions of STOPP and START include a combined 114 evidence-based criteria — up more than 30% from the original. With the STOPP/START criteria, clinicians can potentially decrease polypharmacy by improving medication appropriateness

5. SIMPATHY Analysis Tool

The goal of the SIMPATHY economic analysis tool is to provide a high-level analysis of the economic costs and benefits associated with carrying out polypharmacy reviews. The analysis follows a top-down approach and estimates maximum costs and benefits associated with activity.

Sources: Adopted from WHO, NCBI, AGS and European Commission

Conclusion

Hospital management plays a significant role in reducing inappropriate polypharmacy and ensuring medication safety. Taking a systems approach with multidisciplinary clinical and policy leadership is good starting point. Nurture a culture that encourages and prioritizes medication safety in your organization. Streamline and standardize your policies, procedures, and protocols as these are critical in managing polypharmacy risks. This applies from initial prescribing practices to regular medication reviews.
 

Adopt one or more of the strategies described above to reduce polypharmacy. Deprescribing is one of the most effective ways. Using tools and technology appropriately to support implementation can be useful and effective. This includes having an online incident reporting system for medication error reporting. Finally, educate and empower your patients with the right information to make informed decisions. This can go a long way in ensuring the safe use of medicines.

Strategies to Reduce Medication Errors in High-risk Situations

Celina B
medication errors in high-risk situations

In our previous blog Medication Safety – A Priority in Patient Safety, we briefly touched on the three priority areas where medication errors are most likely to happen. These are certain high-risk situations, when patients are using multiple drugs, and during transition of care.

 

We will be discussing strategies to reduce medication errors in high-risk situations in this blog. In the context of medication safety, high-risk situations relate to those circumstances associated with a significant risk of medication-related harm, such as situations arising from look-alike, sound-alike (LASA) medications and high-alert medications. WHO has grouped high-risk situations into three broad factors:

1. Medication factors
2. Provider and patient factors
3. Systems factors (work environment)

Medication Factors

Medication factors include the use of high-risk (high-alert) medications, often medicines with a low therapeutic index. The development of local high-risk medication lists that are regularly updated help healthcare professionals focus on particular risks in their own workplace. However, merely creating a high-risk medication list without associated risk reduction strategies will not be enough.

 

Strategies to reduce harm from high-risk (high-alert) medications

Due to the complexity of systems in healthcare, the Institute for Safe Medication Practices (ISMP) has highlighted that a single strategy for addressing the risks associated with each high-risk (high-alert) medication in the acute care setting is rarely sufficient.

The following measures may therefore be considered to ensure medication safety:

    • ● Maximize access to provide necessary information on medications when critical tasks are being performed.

       

    • ● Standardize clinically sound, uniform models of care or products to reduce variation and complexity.

       

    • Simplify the number of steps in the process of handovers without eliminating crucial redundancies.

       

    • ● Keep antidotes, reversal agents or remedial measures readily available and ensure staff are appropriately trained to manage such errors.

    • ● Proactively identify risks and minimize their effects. Built in safeguards to prevent or respond to failures.

Provider and Patient Factors

Provider Factor

Provider factors may be related to the healthcare professional providing patient care or the patient being treated. Poor prescribing practices by healthcare professionals include over-prescribing, under-prescribing and misprescribing. All of these potentially inappropriate prescribing can contribute to an unfavorable risk–benefit ratio, and reduce the benefits of these medications to the patient.


Healthcare professionals are also involved in ensuring safe storage, preparation, dispensing, administration and monitoring of medications. These different steps of the medication use process are no longer the sole responsibility of any single healthcare group. However, it is vital that there is good communication between different groups of healthcare providers. 

Resource-limited healthcare settings are often characterized by a lack of electronic support systems for prescribing or dispensing, overcrowding of patients, staff shortages and inadequate monitoring. In such circumstances poor prescribing practices, such as the use of error-prone abbreviations or illegible handwriting increase the risk of medication errors.

Patients Factor

It is well known that adverse drug events occur most often at the extremes of life (in the very young and elder people). In elderly, who are likely to be receiving several medications concomitantly, adding to the risk of adverse drug events. In addition, the harm of some of these medication combinations may sometimes be synergistic and be greater than the sum of the risks of harm of the individual agents.

Polypharmacy was the second major factor predicting risk of experiencing a medication error in adult inpatients and increased risk of harm.

Multi-morbidity is becoming more prevalent as life expectancy increases in many countries around the world. A meta-analysis that included 75 studies from primary care demonstrated that mental-physical multimorbidity was associated with an increased risk of harm.


High-risk medical conditions
predispose patients to an increased risk of adverse drug reactions, particularly renal or hepatic dysfunction and cardiac failure (where both kidney and liver can be compromised together).

 

Strategies to reduce medication errors related to provider and patient factors

There should be a systems approach to counter the effects of human fallibility. This approach concentrates on the conditions under which people work and endeavors to build the defenses required to avert errors or limit their effects.

    • At the prescribing level: pharmacist/nurse to ensure appropriate medicine, dose, route and duration written for the right patient in the prescription by a certified medical practitioner.

    • At the storage level: Ensuring medications stored accordingly to the right storage conditions and right labeling. Also, best arrangement practices are often associated with LASA and FIFO principles (LASA – Look Alike, Sound Alike & FIFO – First In First Out).

    • ●  Standardizing the medication preparation, dispensing and administration following the rights – either 6R, 7R or 10R, whichever applies to the organization’s policy.

       

    • ● Inter-professional educational initiatives may help healthcare professionals to learn to work better together in multidisciplinary teams to promote patient safety.

       

    • ● Principles of co-production of resources and partnership with patients and caregivers should be applied in relation to developing systems.

       

    • ● Core prescribing competencies are relevant to all the prescribing providers who are faced with addressing the increasing burden of complex polypharmacy.

       

    • ● Patients should be supported by an effective prescribing team working in close partnership to ensure they are aware of the purpose of all medications taken, their likely benefits and potential risks.
Systems Factors

Systems factors (work environment) include the hospitals and high-risk situations within those settings (e.g. risks associated with perioperative or neonatal care). The environment in hospitals can contribute to error-provoking conditions. The clinical ward may be busy or understaffed, contributing to inadequate supervision or failure to remember to check important information. Interruptions during critical processes (e.g. administration of medicines) can also occur, which can have significant implications for patient safety. Tiredness and the need to multitask when busy can also contribute to medication error.

Strategies to reduce medication errors related to systems factors

    • ● Developing a plan to achieve those objectives, including the processes, systems, patient involvement and training of healthcare professionals.

    • ● Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication-related errors in the work environment

    • Tables giving information on drug–drug interactions, and interactions with traditional and complementary medication are also helpful, particularly in situations where polypharmacy is common.

    • ● Prescribing assessment tools can also be helpful. Building on the original Beers Criteria (for potentially inappropriate medication use in older adults), the STOPP (Screening Tool of Older Person’s Prescriptions) criteria has been developed to highlight potentially inappropriate medications.
Conclusion

Medication errors account for 50% of all preventable medical harm globally. It is an area that requires urgent actions by all stakeholders. Appropriate strategies should be implemented to reduce medication errors in high-risk situations involving medication factors, provider and patient factors, and systems factors. These strategies can form part of your organization’s patient safety programs to reduce the risk of medication errors, supported by a strong patient safety and reporting culture, along with training and feedback loop.

QUASR incident reporting system has built-in incident types including medication errors. It has pre-configured forms to capture the type of medication error, severity, type of medication/ substance involved, incorrect action, incorrect dose, and other relevant information. These forms are easily configurable to suit various healthcare settings. Hospital management can gain useful and actionable insights from the medication error reported and dashboards generated.

Book a demo with us to find out medication error reporting in QUASR

Medication Without Harm – A Priority in Patient Safety

Celina B
Medication-Safety

Image Source: WHO

Are medication errors one of the most frequently reported incident types in your hospital? What can be done to prevent medication errors? Is medication-related harm avoidable? According to the WHO, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care globally. Medication-related harm represents 50% of all preventable harm in medical care and remains a critical patient safety issue.

Against the backdrop of Covid-19 pandemic, ‘Medication Safety’ has been aptly selected as the theme for World Patient Safety Day (WPSD) 2022, with the slogan ‘Medication Without Harm’. This year’s campaign also provides a platform to reenergize the WHO Global Patient Safety Challenge: Medication Without Harm launched in 2017.

 

QUASR joins the WPSD campaign to promote awareness and urge all stakeholders to address medication safety as a priority in patient safety across all levels of healthcare.

Objectives of World Patient Safety Day 2022

The objectives of WPSD 2022 are as follow:

 

  • 1. RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE urgent action to improve medication safety.

    2. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm.

  • 3. EMPOWER patients and families to be actively involved in the safe use of medication.

  • 4. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm.

Source: WHO WPSD 2022

Important Factors that Influence Medication Errors

Medication errors occur when weak medication systems and human factors such as fatigue, poor environmental conditions or staff shortages, task, and the primary-secondary care interface affect the safety of the medication process. This can result in severe patient harm, disability and in some cases even death.

List of factors that influences the medication errors:

●  Lack of therapeutic training

●  Inadequate drug knowledge and experience

●  Insufficient knowledge of patients record

●  Overworked or fatigued healthcare professionals

●  Physical and emotional health issues

●  Poor communication between healthcare professionals and patients

●  Lack of standardized policies, protocols and procedures

●  Issues with physical work environments (eg: lightings, and ventilators)

●  Complexity in naming of medicines, labeling and packaging

●  Limited quality of communication with secondary care

●  Distractions and interruptions by other staff or patients

What Can Organizations Do to Enhance Medication Safety?

All medication errors are potentially preventable. They can be greatly reduced by improving the systems and practices of medication prescribing, transcribing, dispensing, administration, and monitoring. A fundamental step in enhancing medication safety is that healthcare organizations must be familiar with the medications that are available to treat their patients. There are several ways to accomplish medication safety:

    • ► Maintain up-to-date references of current medications and have those references available at the time the drug is prescribed.

    • ► Proper container labels to help healthcare providers and patients select the right drug. If a drug is made in multiple strengths e.g., 5 mg, 10 mg, and 25 mg, the labels of those three containers should be easy to differentiate.

    • ► In depth knowledge of potential interactions between a newly prescribed medication and other medications already being used by the patient, including non-prescribed medications and supplements, as well as treatments being considered.

    • ► Recognize the potential risk of high-alert medications, those drugs that bear a heightened risk of causing severe patient harm if there is an error in the medication-use process.

    • ► Electronic prescribing (also known as e-prescribing) refers to a prescribers ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care

    • ► Medication orders should be legible and must include the following components: name of the drug, dose, route of administration, frequency, reason or conditions under which the drug should be prescribed, and patient’s weight and age

    • ► Engaging the patient in their own care may improve adherence, patient satisfaction, and also reduce opportunities for medication errors. This requires the concerted effort of all members of the medical team, both in and out of the hospital.

    • ► Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication errors. Equally important is the fact that their effect depends on the success with which they are integrated into well-designed care processes.

Priority Areas to Prevent Medication Errors

WHO has identified three key areas to focus on to protect patients from medication harm. Medication errors are more likely to occur in certain high-risk situations, when patients are using multiple drugs, and during transitions of care.

 

A. High-risk situations

The impact of medication errors is greater with treating inpatients in a hospital. This may be related to the more acute clinical situations in these settings and the use of more complex medications. Young children and the elderly people are more susceptible to its adverse effects. Medication errors in such scenarios often involve the administration of the wrong dose and a failure to follow proper treatment regimes.

B. Polypharmacy

Patients using four or more drugs at the same time are also in a critical situation and extra care should be taken to prevent harm. Polypharmacy increases the likelihood of side effects, as well as the risk of interactions between medications, and may cause severe harm. If a patient requires many medicines, they must be utilized in an optimal manner, so that the medicines are appropriately prescribed and administered, to ensure that they produce significant benefits with minimal side effects.

C. Transitions of care

Patients are at greater risk during transitions of care. For example: a transfer from the emergency room to the intensive care unit, from a specialty center to a bigger hospital, from a primary care doctor to a specialist, or from one nurse to another during a shift change. Serious mistakes can and do occur at these times.

Source: Adopted from WHO Global Patient Safety Challenge: Medication Without Harm

Next Steps

The Global Patient Safety Challenge on Medication Safety launched in 2017 set a goal of reducing the level of severe, avoidable harm related to medications by 50% over 5 years, globally. It is an inspirational goal. We tried to look for some statistics to see how far we have progressed over the last 5 years but could not find any. We believe gathering reliable data for measurement and comparison is a big challenge.

For healthcare organizations, perhaps you want to focus on capturing medication safety incidents in your hospital and learning from them.  To do it effectively, quality and risk management teams can adopt digitized incident reporting systems to capture, investigate and analyze root causes of medication errors, especially in the high priority areas described above.

 

In the upcoming blogs, we will deep dive to discuss medication safety in high-risk situations, polypharmacy and transitions of care in detail.

Book a demo with us to find out medication error reporting in QUASR with

  • ● Digitalized workflow and notifications
  • ● Configurable medication error types and forms
  • ● Categorizing medication errors
  • ● Risk assessment, investigation, RCA and more