ATrain Education

 

Continuing Education for Health Professionals

FL: Preventing Medical Errors

Module 5

Vulnerable Populations

 

Children are at particular risk of medication errors . . . this is attributable primarily to incorrect dosages.

Institute of Medicine, 1999
To Err is Human: Building a Safer Health System

 

Anyone who takes medication has some risk of a harmful effect. There are some groups, however, that have an increased risk of adverse medication events. Children, the elderly, and those with limited English skills and/or poor health literacy are at a high risk for adverse events.

Children

Take a look at the vitamins on the shelves at your local drug or grocery store. They come in an amazing array of colors, flavors, shapes, all looking—and tasting—very much like candy. Some pharmacies can even custom blend flavors such as chocolate, vanilla and bubble gum for children’s medications. Is it any wonder that finding and eating or drinking medicines on their own without adult supervision is the leading cause of emergency visits for adverse drug events incurred in the community among children less than 5 years old? An estimated 53,000 children less than 5 years old are brought to emergency departments each year because of unsupervised ingestions (CDC, 2010d).

Pediatric patients face four distinct issues that set them apart from the rest of the hospital population, making it a high-risk environment for hospitalized children:

  • Development. As children mature both mentally and physically, their needs for healthcare goods and services change.
  • Dependency. Hospitalized children are dependent on caregivers and parents to convey key information and their care must be approved by parents or their surrogates during all encounters.
  • Different epidemiology. Most hospitalized children require acute episodic care, not care for chronic conditions as with adults.
  • Demographics. Children are more likely to live in poverty and experience racial and ethnic disparities in healthcare, and they are more dependent on public insurance (Hughes & Blegen, 2008).

Medication errors are the most common adverse event experienced by pediatric inpatients. Often pediatric indications and dosage guidelines aren’t included with a medication, necessitating weight-based dosing or dilution, which, in turn creates more opportunity for error (PSNet, 2015; Hughes & Edgerton, 2005).

Preventing Medical Errors for Pediatric Inpatients

Children are not simply little adults; their physiology and mental development are vastly different from adults. While many of the same medical error prevention techniques for adults are perfectly acceptable for pediatric patients (eg, hand hygiene), others need more consideration.

In many settings, children are still weighed in pounds instead of kilograms. This can add another layer of complexity to calculating medication dosage, which is often based in kilograms. An AHRQ study recommended recording pediatric patients’ weight in kilograms to make calculating medication dosages easier (AHRQ, 2009).

In another study funded by AHRQ, researchers found increased error incidents in the pediatric ICU and recommended developing protocols for high-risk procedures, improved monitoring, staffing, training, and communication initiatives (AHRQ, 2013b).

Elders

Elderly patients are prescribed more than 30% of all prescription drugs. Adverse drug events or reactions to medicines are implicated in 5% to 17% of inpatient admissions (Alexander & Wang, 2014).

Elders in the Community

For many older adults in the community, the ability to remain independent in their homes depends on the ability to manage a complicated medication regimen. Non-adherence to medication regimens is a major cause of nursing home placement in older adults. In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems at an annual cost of more than $14 billion (Hughes & Blegen, 2008).

As people age, they typically take more medicines. Older adults (>65 years) are twice as likely as others to come to emergency departments for adverse drug events (over 177,000 emergency visits each year) and nearly 7 times more likely to be hospitalized after an emergency visit (CDC, 2012b).

Most of these hospitalizations are due to a few drugs that require careful monitoring to prevent problems. These include blood thinners such as warfarin, diabetes medications like insulin, seizure medications such as phenytoin and carbamazepine, and heart medicine such as digoxin (CDC, 2012b).

Poor cognition is associated with inability to follow medication regimens. Forgetting is a major reason medication doses are missed. The most common type of noncompliance is dose omission, but over-consumption is also a mistake frequently made by older people (Hughes & Blegen, 2008).

Older adults have narrow therapeutic windows and require close monitoring, especially when on multiple medications. A review of emergency department visits of patients 65 years and older found that more than 10% of the visits were related to an adverse drug event and more than 30% had at least one potential adverse drug interaction in their medication regimen (Hughes & Blegen, 2008).

Poor vision and decreased manual dexterity are also problems for elders. It is common for medication bottle caps to be left off or not properly closed so the patient can access the medicine. One study showed that almost one-half of older patients stated that they were not able to read the labels on the bottles due to poor eyesight, inability to read English, or small writing on the bottles (Hughes & Blegen, 2008).

Another cause of non-adherence in elders is difficulty with medication procurement. In a study of elders at 15 days after hospitalization, 27% had not filled their new prescriptions (Hughes & Blegen, 2008).

Preventing Medical Errors for Elders in the Community

Medication reconciliation is the first step in helping older adults with medication management. Multiple studies have shown discrepancies as high as 66% in medications that were ordered and those actually being taken (Hughes & Blegen, 2008).

Pharmacy resources, such as medication reviews and computerized medication interactions programs, are effective tools to reduce adverse drug events in older patients. Patients who participate in pharmacy delivery programs and refill reminders have higher compliance than those who do not (Hughes & Blegen, 2008).

Hospitalized Elders

The older patient has increased risk for functional decline during hospitalization due to decreased mobility and other risks of hospitalization. They may also experience delirium due to a medical condition, leading to cognition issues in compliance with care. Beyond medication errors, frail elderly in the hospital have a higher risk for falls, hospital-acquired infections, and pressure ulcers (Hughes & Blegen, 2008).

Preventing Medical Errors for Hospitalized Elders

The elderly acute-care patient will benefit from the same medical error preventions as the rest of hospital population, but particular attention should be paid to falls, pressure ulcers, and hospital-acquired infections (Hughes & Blegen, 2008).

Those older than 65 with cognitive issues have the greatest risk for falls in the acute-care setting (Hughes & Blegen, 2008).Interventions for falls can include such protocols as frequent rounding and fall-risk assessment tools (see Medical Errors, Patient Falls section) (DuPree et al., 2014).

Elders are also among those at highest risk for pressure ulcers. Interventions for preventing pressure ulcers can include good skin hygiene and frequent position changes (see Medical Errors, Pressure Ulcers section) (MedLine Plus, 2014).

Patients with Limited Health Literacy

Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It includes the ability to understand instructions on prescription bottles, appointment slips, medical education brochures, doctors’ directions, and consent forms, and the ability to negotiate complex healthcare systems (NN/LM, 2013).

The burden of health literacy on those who have difficulty understanding English is enormous. Nearly 25 million people in the United States (8.6 %) are defined as limited English proficient, meaning that they speak English less than “very well.” Therefore, at least 8.6 % of the U.S. population is at risk for adverse events because of barriers associated with their language ability (Betancourt et al., 2012).

In fact, a 2010 study examined the claims of a single malpractice carrier that insures in four states and found that 35 medical malpractice claims resulted in $2,289,000 in damages or settlements and $2,793,800 in legal fees largely due to communication issues. In one particular case cited, a 9-year-old child, who was the patient, acted as interpreter for the family (Quan, 2010).

Communication problems are the most frequent root cause of serious adverse events reported to the Joint Commission’s Sentinel Event Database (Betancourt et al., 2012).

The Joint Commission notes that “health literacy issues and ineffective communications place patients at greater risk of preventable adverse events.” Studies have shown that lower health literacy is linked to a lower likelihood of getting flu shots and of understanding medical labels and instructions, and a greater likelihood of taking medicines incorrectly. It is also linked with poorer health status, less use of preventive care, more likelihood of hospitalization, and bad disease outcomes. The annual cost to the U.S. economy of low health literacy is estimated to be between $106 billion and $238 billion (NN/LM, 2013).

Populations most vulnerable to poor health literacy include:

  • Older adults. Adults over 65 use more medical services and acquire more chronic illnesses than other population groups, yet 71% have difficulty using printed materials, 80% have difficulty using forms and charts, and 68% have difficulty interpreting numbers and making calculations, and it is estimated that two-thirds do not understand the information regarding their prescription medications.
  • Minority populations. The number of adults at the “Below Basic” level is higher among Hispanics (41%), American Indian/Native Alaskans (25%), Blacks (24%), and Asians (13%) than among whites (9%).
  • Low income. Adults living below the poverty level have a lower average health literacy than those living above the poverty level (NN/LM, 2013).

Preventing Medical Errors in Those with Limited Health Literacy

The AHRQ recommends a number of actions to mitigate the issues of medical errors among those with limited health literacy:

  1. Develop dedicated services for interpretation that include qualified medical interpreters, in person or by telephone.
  2. Provide patients with written materials, such as informed consent forms or procedure instructions, in their preferred written language.
  3. Identify patient’s language needs on boards on the inpatient floors that list current patients and responsibilities.
  4. Create a mechanism to schedule an interpreter automatically at clinical points of service for limited English proficiency patients.
  5. Develop visual cues to remind hospital staff to attend to language and cultural needs.
  6. Train staff on team communication, interpreter use, cultural competency, and advocacy.
  7. Consider other initiatives to improve safety for those with limited English proficiency and culturally diverse patients (Betancourt et al., 2012).
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