Why medication safety is a problem and what providers can do about it

Why are medication practices and/or medication errors such a big issue in health care?

Medications factor prominently into accidental deaths in the U.S. In fact, drug overdoses are the leading cause, and opioids account for more than 60 percent of drug overdose deaths. Consequently, the World Health Organization (WHO) has taken notice, choosing Medication Safety as the theme for this year’s world patient safety day. Additionally, medication management is where most providers can make the greatest impact within their professional practice arena.

Data from closed claims shows that medication management is a risky area, most prominently monitoring the treatment plan. Monitoring and management begin when the patient receives the prescription and continues until the patient is no longer taking it. An effective risk management process is essential for safe patient care. Having current patient medication information will assist with subsequent prescribing and a care plan.

How prevalent are serious medication errors?

Over the past ten years, around 6.5 percent of all major allegations made against members of The Doctors Company involved medications. With most of those claims (65%) occurring in an ambulatory or outpatient setting, implications for how clinicians approach medication safety in their practices are significant.

The most serious cases often include the negligent prescription of opioid medications. With opioids, patients are typically requesting and being given higher and higher doses, with allegedly insufficient oversight and monitoring. Those adverse events can be very serious, including the death of the patient, and the consequences that follow often include criminal penalties for the practitioner.

What can healthcare providers do to promote medication safety and the best practices?

When it comes to promoting medication safety, there are three key areas all healthcare providers should focus on:

Engage Patients in Medication Safety

• Assess the patient’s medication history, including current and any medications prescribed in the past that caused side effects or were not well tolerated. It is vital that the medication history include prescription drugs, recreational drugs, over-the-counter drugs, supplements, and herbal medications. Patients may not always be forthcoming and may not be reliable historians. Obtain medical records from other providers, including hospitals, and ask the patient to bring in any medication bottles on hand to improve the completeness and accuracy of your records.
• Ask targeted questions to ascertain patient compliance with medications, including not taking them, changing their dosage, or not taking them as prescribed. Enlist the help of a family member or friend (if permitted by the patient) to assist with medications and to alert you to nonadherent behaviors.
• Address any health care literacy issues. One way to verify understanding is to ask patients to explain in their own words how they will take the medications. If that process is used, document the verification in your medical record. When patients return, have them repeat exactly how they are taking their medications.
• Obtain informed consent for medications prescribed and document the patient’s understanding of the risks.

Stay Up to Date and Put Protocols in Place

• Query state prescription drug monitoring programs to identify other prescribers who may be prescribing the same or similar medications.
• Screen patients at each visit for vital signs, weight loss or gain, skin rashes, and other objective findings that may be due to the medication prescribed.
• Develop an office tracking process for patients who take drugs that require periodic monitoring with specific lab tests (e.g., lithium). Establishing an effective process can prevent omissions or timing errors in lab testing.
• Provide additional monitoring and oversight when using polypharmacy (combinations of medications to improve outcomes), as there may be a heightened likelihood of drug interactions and side effects from the combination. Ideally, controlled trials for polypharmacy would increase patient safety, but few studies exist. The paucity of research studies places a greater burden on the clinician.

Be Collaborative & Communicative

• Share information with others caring for the patient concomitantly and solicit information from them that is relevant to your current treatment. Regular contact with the patient’s primary care physician may be particularly valuable. Document these interactions in the medical record.
• Standardize practices for delivering detailed instructions and counseling to patients regarding how to take medications and what to watch for as possible side effects. Ensure all staff are familiar with available patient handouts—even those directly from the drug manufacturer. If any handouts are given to the patient, document the information in the medical record for future reference and be sure to avoid having staff members distribute handouts that they have not personally read and support.
• Foster a culture of trust and collaboration in your practice. When things go wrong, as they occasionally do, it’s important that healthcare providers at every level feel empowered to communicate what has happened so the appropriate response can be enacted quickly. Establishing this type of a culture of mutual respect is critical.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Richard F. Cahill, JD, is Vice President and Associate General Counsel for The Doctors Company. The 35-year healthcare litigation veteran provides legal support to the Claims and Patient Safety departments.

David L. Feldman, MD, MBA, FACS, is Senior Vice President & Chief Medical Officer of Healthcare Risk Advisors (HRA) and Chief Medical Officer of TDC Group. A renowned patient safety advocate, he has spoken with numerous leaders in the field of patient safety for Leading Voices in Healthcare.