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The federal "Indicators" for surveyor assessment of the performance of drug regimen reviews (originally developed for use by nursing home surveyors in their periodic facility surveys) identify 32 "irregularities" or drug-related problems (DRPs) that should serve as minimal standards for drug regimen review in older patients (see Appendix). The purpose of this article is to overview management of all types of DRPs that can occur in elderly patients, as a more optimal standard for drug regimen review and therapeutic management.
DRPs are defined as any unwanted or unintended consequence of the administration or nonadministration of medications. There are two general types of DRPs: (1) medication errors and misuse by any person associated with drug prescribing, filling, administration, and assessment, and (2) adverse drug reactions and interactions.
A recent two-year study (Cooper, 1986) of DRPs in nursing homes found that up to two-thirds of monthly drug regimen reviews performed by pharmacists revealed a significant DRP in this patient population (see Table 1). A further study of patient admissions to nursing homes found that up to one-half of admissions were associated with DRPs of drug class duplication, unnecessary drug therapy, drug therapy needed for newly identified problems, suspected drug reactions, and lab data needed to evaluate drug therapy (Cooper, 1987c). Up to one-third of elderly admissions to hospitals are associated with DRPs (Frisk, Cooper and Campbell, 1977).
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The checklist on page 25 details a problem list and drug regimen review process that can be used in these studies. There is a recently published guideline for monitoring drug therapy in older patients (Cooper, 1993).
Patients' suspected DRPs should be identified to the attending prescriber through whatever means possible. The principle of pharmaceutical care, however, assumes that the pharmacist undertakes an ever greater responsibility for therapeutic outcome. It is important to realize that medication errors can also occur throughout the drug use process and that errors can be made by all four participants in that process: the patient and his or her caregivers, the prescriber, the nurse or person administering the medication, and the pharmacist (Cooper, 1991, 1993).
Many types of medication errors can occur with the elderly patient. A medication error as defined in a total system sense is an act of commission or omission pertaining to the prescribing, dispensing, or administration of drugs. Clinical ramifications of medication error may range from insignificance to terminal consequences. Unfortunately, healthcare professionals involved in prescribing, dispensing, and administering drugs make characteristic errors, as do patients, so medication errors are made by professionals as well as patients. Patients whose medication errors are chronic are considered to be noncompliant. The subject of noncompliance is thoroughly discussed in the article by Frank Ascione, entitled "Medication Compliance in the Elderly," in this issue.
Prescriber medication errors. It is essential to have a complete and appropriate drug order for the patient to minimize the likelihood of medication error. Prescriber errors include the following:
1. Incorrect or confusing nomenclature (abbreviations, acronyms, or symbols). Only standard nomenclature should be used.
2. Inappropriate dosage. Lean body weight and assessment of renal and hepatic function must be used. Dosage requirements may be 20 to 50 percent lower for the elderly patient.
3. Failure to specify dosage strength or appropriate form.
4. Failure to specify exact dose.
5. Incorrect or unspecified route of administration or dosage form--orally versus intramuscular injection, for example.
A concise formulary of specific medications approved for use in a particular facility helps to rectify errors 3, 4, and 5 above. Those dispensing and administering the drug must also clarify any apparently incomplete information before proceeding in the drug use process.
6. Failure to provide complete information to the patient and/or caregiver to understand and responsibly use the medication.
7. Inappropriate delegation of authority. Clear lines of responsibility must be established. For example, when a refill or dose change authorization is made by the prescribing office, how often does the prescriber actually participate in the decision process and adequately document the change or authorization?
8. Illegibly written orders.
9. Confusing oral orders. Clarification of all is essential.
10. Failure to look at total problem list and medication profile of the patient before prescribing.
11. Failure to periodically assess the need for continued therapy.
All health professionals must contribute to the assessment process in 6 through 11 above, as well as provide cross checks in all types of errors to minimize their occurrence.