Strategies to Reduce Medication Errors in Ambulatory Practice: Prevention Strategies for Primary Care Physicians part 3
Enlist the help of local pharmacists and encourage patients to ask pharmacists about their medications and ADR
Physicians should remember that they have a good source of drug information in local pharmacists. Patients as well as physicians should actively interact with pharmacy personnel to obtain drug information. Physicians should work with local pharmacists to minimize medication errors. This becomes especially important in patients who see other physicians and use multiple pharmacies. Physician-pharmacist interaction should be made to work for the good of our patients.
Verbal orders over the phone should always be repeated by the pharmacists before the call is considered complete. Physicians need to be aware of “sound alike” drugs when making phone calls. To limit errors, the indication for the use of any agent called in should also be discussed with the pharmacist. In addition, automatic refills of certain medicines should only be encouraged if constant review mechanisms are in place at the offices of the primary physician and the pharmacist to avoid ADRs.
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Improve knowledge of commonly used herbal therapies Primary care physicians should attach some importance to the issue of keeping up-to-date with the changes going on in the realm of herbal therapy. The use of herbal or natural products is growing significantly in this country. Americans spend approximately $3 billion annually on herbal products. Physicians need to know that some patients do not consider herbal supplements to be medicinal agents and will not provide a history of use unless specifically asked. As noted by Jaski et al., review and documentation of nonprescription substances are uncommon in primary care practice. Primary care physicians should realize that the review and documentation of all medications at each visit can be an effective safeguard against medication errors.
Physicians need to become familiar with commonly used herbal agents. Doctors need to know the potential therapeutic benefits of these agents. Doctors also need to know if patients are being exposed to harm by utilizing these herbal preparations. The nature of such risks and the potential for drug-drug and drug-disease interactions should be studied. A good reference for this is Natural Medicines Comprehensive Database published by Therapeutics Research.
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Be aware of dangerous drug-drug interactions: ask about consumption ofgrapefruit juice/Improve your basic knowledge of the cytochrome P450 drug metabolizing system
In a survey of potential drug interaction incidence in an outpatient clinic setting, Stanaszek and Franklin reported an adverse drug reaction rate of 23%. The key to avoiding harmful drug interactions is to recognize and monitor patients at high risk. Elderly patients are at the greatest risk of drug interactions because they take multiple medications for a variety of reasons. The following medications should be closely monitored for potential interactions when given with other agents to elderly patients; antiarrhythmic agents, antacids, antipsychotics, calcium antagonists, centrally acting analgesics, generic digoxin, diuretics, nonsteroidal anti-inflammatory drugs, oral hypoglycemic agents, phenytoin drug, theophylline tablet, tricyclic medication antidepressants and Generic Coumadin. Patients who see other prescribing specialists are also at high risk, and it is important to review all medications after a patient returns from a specialist consultation.
Beware of interactions involving grapefruit juice. Drugs that interact with grapefruit juice undergo cytochrome P450 oxidative metabolism in the intestinal wall or liver. Grapefruit juice contains fura-nocoumarin derivatives that inhibit metabolism by CY1P3A. Grapefruit juice increases the serum drug concentration of canadian amiodarone, astemizole, cyclosporin, carbamazepine tablet, midazolam, diazepam, lovastatin canadian, simvastatin drug, generic atorvastatin, verapamil tablet and the dihydropyridine calcium channel blockers.
Physicians need to be aware that some herbal medications may induce toxicity via the cytochrome P450 pathway. Herbal supplements known to have cytochrome P450 enzyme activity include kava, Ginkgo biloba, chili pepper and black pepper. Drugs metabolized at the level of cytochrome P450 generally have one of two effects, enzyme inhibition or enzyme induction. For commonly prescribed drugs, primary care physicians should anticipate drug interactions by familiarizing themselves with the effects of these agents on the P450 enzyme system.
Maintain vigilance and review the drug list of patients reporting new symptoms on initiating additional drug therapy.
Do not forget drug-disease interactions
As a classic example, the patient with chronic obstructive pulmonary disease (COPD) who presents with worsening symptoms may be on a beta-adrenergic blocking drug. In addition to COPD, beta-adrenergic agents can often precipitate and cause exacerbation of diseases, such as asthma and peripheral vascular disease. buy antibiotics canada
Elderly patients on drugs causing anticholinergic effects may present with worsening lower urinary tract symptoms of benign prostatic hyperplasia, constipation and glaucoma. The adverse effects, dry mouth, urinary retention and confusion caused by some of these anticholinergic agents warrant their constant review in elderly patients. The symptoms above and others, such as lethargy, weakness, falls and dizziness, should always prompt review of medications in an attempt to avoid the prescribing cascade that occurs when additional drugs are prescribed to treat drug-induced symptoms.
Table 4. Partial List of Websites with Special Focus on Medication Errors
| AHRQ Medical Errors and Patient Safety Research Page |
| American Hospital Association |
| American Society of Health-System Pharmacists
Institute for Safe Medication Practices |
| Mederrors.Com |
| National Coordinating Council for Medication Error Reporting and Prevention |
| National Patient Safety Foundation |
| Institute for Healthcare Improvement |
| Quality Interagency Coordination Task Force |
| U.S. Pharmacopoeia |
CONCLUSION
Physicians engaged in ambulatory practice need to be proactive in making the use of medications safer. It is only through constant vigilance that doctors can decrease the incidence of ADR and medication errors. They should work with patients and other healthcare providers to reduce the number of errors in prescriptions and drug administration. They must also participate in the postmarketing surveillance program established by the FDA. The MedWatch program is the safety information and adverse event reporting program of the FDA. MedWatch is important since the data generated can only lead to more prudent prescribing. cialis soft tablets
For physicians wishing to obtain further information on medication errors, Table 4 provides a list of websites that contain relevant information on this subject. Most of these websites provide various resources, references and links to sites aimed at patient education as well.
