Strategies to Reduce Medication Errors in Ambulatory Practice: Prevention Strategies for Primary Care Physicians part 2
Take a drug history/document drug allergy
A poor drug history may lead to a failure to detect unintended drug effects. A drug history should include the use of alternative medicines or herbal medications, supplements and other over-the-counter (OTC) medications. A recent study indicated that review and documentation of nonprescription substances are uncommon in primary practice. Of 655 physician respondents, only 47% documented herbal and other alternative treatments in the medical record. Physicians should always ask patients about allergies to drugs and should make sure the allergy history has been clearly documented and prominently displayed on the front of the patient’s chart. When a doctor prescribes a new medication, he/she should always be sure to ask if the patient has used the drug before and if any unpredictable reaction occurred. Physicians should encourage patients with serious allergic reactions to wear medic alert bracelets or necklaces.
Keep your medication/drug list up-to-date
The maintenance of a medication list is a vital link in alerting the physician to possible drug-drug as well as drug-disease interactions. Physicians need to be mindful of the possibility of drug interactions as new medications are added. It is important to remember to add to the chart medications being provided by subspe-cialists. Conduct medication reviews periodically in your practice and recruit the help of local pharmacists in this endeavor to ensure that your patients are taking the right medications safe from preventable errors. canadian pharmacy cialis
Have patients who are on multiple drugs—especially if elderly—bring medications to follow-up visits. Elderly patients especially are more prone to ADR. They are dealing with multiple, complex medical problems requiring several agents. In addition, the normal physiologic changes that occur with aging place the elderly at increased risk for ADR (Table 2). Primary care physicians will be faced with an ever- increasing elderly population given the projected demographics of the next several years, so understanding some basic facts and principles of geriatric clinical pharmacology should be considered an important primary care issue. A few numbers should help illustrate this point. Although persons aged 65 and older represent only 12% of the population, they account for more than 25% of prescription medications consumed in the United States Elderly individuals use, on average, 4.8 prescriptions and OTC medications on a daily basis. These numbers also mean that polypharmacy and possible drug-drug interactions are important issues for the elderly in the outpatient setting.
Pay attention to the use of fixed-dose combination medication products in the elderly and other patients Physicians should always document the active ingredient in such combinations in the medication list to prevent potential problems.
Table 2. Geriatric Clinical Pharmacology Some Important Physiologic Changes Impacting Drug Effects in the Elderly
| Physiologic Change | Example of Drug Effect |
| Reduction in lean body mass | Drugs, such as digoxin, which bind to muscle Na/K |
| ATPase may have an increased effect in the elderly on | |
| account of reduction in lean body mass and resulting | |
| decrease in volume of distribution. | |
| Increase in proportion of adipose tissue with | This results in many lipid-soluble drugs having a more |
| aging. | prolonged half-life in the elderly. This has clinical |
| relevance when prescribing agents that act on the | |
| central nervous system. | |
| Decrease in plasma proteins and declining | Albumin levels decrease in the elderly and, as a result. |
| levels of hepatic drug metabolizing enzymes. | a more active drug is available to exert therapeutic as |
| well as unwanted effects. | |
| Decrease in glomerular filtration. | The physiologic decrease in glomerular filtration may |
| result in a deficiency of drug processing ability and | |
| impairment of drug elimination, placing the elderly at | |
| risk of adverse drug effects. |
Note that some elderly patients may use multiple doctors as well as pharmacies. Physicians may need to work with such patients to make it easier to manage and coordinate their medications by discussing use of a single pharmacy, if at all possible. Patients should be encouraged to make a list of all current medications. Table 3 outlines important principles to enhance medication use in elderly patients.
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Pay attention to drug labels
It is important to remember that drug labeling details can change as new information is obtained. The Food and Drug Administration (FDA) issues a “black box” warning on labels to alert clinicians to drugs remaining on the market with serious adverse events. These boxed warnings alert physicians to any special restrictions or mode of administration of specific agents. It is especially important to have patients read the labels with each medication refill. New drug information is available at the FDA’s.
Table 3. Geriatric Clinical Pharmacology Promoting Safe Medication Use in the Elderly in Primary Practice
| Review all drugs on your medication list at each clinic visit for your elderly patients. Eliminate those not required. Discourage elderly patients from sharing the medicines of friends and family members. |
| Have pharmacies provide your elderly patients with large-print labels and collaborate to educate patients about adverse drug reactions and other drug effects. |
| Encourage your elderly patients to bring friends or family members to clinic visits for additional “memory” support.
Encourage the use of devices, such as drug calendars and pill boxes, and the use of open containers. |
| Wherever possible, use simple dosing schedules to improve compliance. |
| Have patients disclose use of supplements and OTC medications at each clinic visit. |
| Have elderly patients bring all medications to each clinic visit for review. Encourage discussion of nonpharmacological alternatives.
Check each new symptom/complaint for drug-induced disease in your elderly patients. |
| Remember that for elderly patients you may have to “start low and go slow” and use the lowest possible drug dose to achieve the desired response. |
In addition to label education, primary care physicians should make sure patients understand the rationale for the use of certain medications. Physicians should devote time to explain the disease process and any expected outcome of drug treatment to their patients. Both acceptable and unacceptable effects of medications should be explained to patients to help increase the chances of adherence to the prescribed regimen. Educating patients enhances their role in preventing medication errors. Alert and knowledgeable patients can serve as the last line of defense in preventing medication-related errors. In short, educate before you medicate. Apcalis Oral Jelly
