Safer Prescribing for Older Adults: Clinical and Business Imperatives Aligned
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For the past 6 years, Dr. B had been treating Mr. J for atrial fibrillation. Two years ago, Dr. B’s large multispecialty medical group opened an anticoagulation clinic, and Dr. B referred Mr. J there for ongoing management.
Prior to joining the anticoagulation clinic, roughly 60% of Mr. J’s International Normalized Ratio (INR) results had been within the targeted therapeutic range; for the past 2 years, over 90% of his INRs have been therapeutic. Both Dr. B and Mr. J were pleased with the improved results.
Two months ago, the anticoagulation clinic had an unanticipated staffing shortage and had to temporarily refer its patients back to their primary care physicians. Before Mr. J made an appointment, he had a recurrence of his sinusitis and was treated in the multispecialty clinic’s urgent care setting with a macrolide antibiotic. The urgent care physician checked Mr. J’s INR and told him it was “perfect,” but didn’t mention the need to follow up due to the potential effect of the macrolide on his anticoagulant.
As usual, Mr. J had his prescription filled at a pharmacy two blocks from his house. His regular pharmacist noticed the potential for a drug interaction, but never mentioned it to the patient and never notified Dr. B. The pharmacist knew that Dr. B was part of a large multispecialty medical group that ran an excellent anticoagulation clinic.
Mr. J called his primary care physician for follow-up on his sinusitis and scheduled an appointment for 2 weeks, but never mentioned the new prescription to the scheduling clerk. Two days before his follow-up appointment, Mr. J was admitted to a local hospital with a massive intracranial hemorrhage. Ten days later, after a stormy hospital course, he died of aspiration pneumonia.
How common are events like this? How could they occur in contemporary society? And, most important, how can we prevent them?
HOW COMMON ARE MEDICATION ERRORS AND ADVERSE DRUG EVENTS?
In 2000, the Institute of Medicine estimated that there were 7000 deaths in the United States each year due to medication error.1 Adverse drug events (ADEs) account for roughly 95,000 hospital admissions,2 700,000 emergency department visits,2 over 3,000,000 office visits,3 and countless unreported symptoms annually (Figure 1). By one recent estimate, the United States spends 30% more money treating the adverse health consequences of medications than on all pharmaceuticals combined.4
These are difficult numbers to track. Mr. J was admitted to the Neurology service of his hospital, not the Pharmacologic Toxicity service. Without the ready ability to track these numbers, few groups recognize the true impact of this problem. Even fewer are able to aggressively manage it.
Adverse drug events have been estimated to represent between the 4th and 6th most common cause of death in the United States.5 Between 1983 and 1998, annual deaths from acknowledged prescription errors have tripled.6 Once driven by hospital-based errors, the balance has shifted to the outpatient arena. In 1983, 75% of deaths from medication errors were generated in the hospital environment. By 1993, the ambulatory setting was responsible for 55% of fatal medication errors.7 Clearly, initiatives to improve the safety of medication use must now embrace a focus on ambulatory prescribing.
The medical education process could be more focused on this issue.
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