Tackling avoidable harm in vulnerable populations
How can clinicians ensure patient safety when prescribing medication for elderly patients?
Healthcare professionals are laser-focussed on helping people live happy and healthy lives, but treating thousands of people with unique needs while also facing time and resource constraints is complex and nuanced. From time to time, things will go wrong, and sometimes this can cause avoidable harm to patients.
Avoidable harm, defined as an injury that could have been prevented through appropriate and timely actions during the care journey, remains a persistent issue for healthcare systems. A recent study by the British Medical Journal found that approximately 1 in 20 patients are affected by avoidable harm, and up to 12 percent of cases result in death or permanent disability.1
In the context of medications, avoidable harm can be contributed to through medication errors, adverse drug reactions, unintended drug interactions, and more. Specifically, when a patient takes multiple medications, they face a significantly higher risk from possible adverse reactions, complex contraindications as well as loss of drug efficacy and treatment failure. Collectively, these phenomena are widely referred to as problematic polypharmacy.
Protecting vulnerable populations
In England alone, more than one third of people aged 80 or older regularly take eight or more medications,2 a total that is only expected to grow as the population ages. In the US, 67 percent of elderly Americans take more than five medications (including over the counter drugs and supplements) that could interfere with prescribed drugs.3 If polypharmacy rates increase in line with the current expectations, it is highly likely that more elderly people will be at risk of avoidable harm in the future.
To put this into perspective, a person who takes more than ten medications is 300 percent more likely to be admitted to hospital because of an adverse drug reaction (ADR).4 And behind every ADR statistic is a lived experience that will be familiar to many people. For instance, an elderly person taking medication to reduce blood pressure has a higher risk of falling as a direct result of the medication — potentially leading to ongoing pain, loss of mobility or even a reduction in independence.
“A comprehensive medicines reconciliation assessment must be carried out by prescribers, pharmacists and nurses in collaboration with patients and/or caregivers to promote optimal drug therapy management, and address deprescribing strategies to mitigate the risks of polypharmacy. The ARMOR protocol, a tool used in long-term care facilities since 2009, is well-suited for an interdisciplinary approach to improve outcomes in outpatient settings.”5
– Fabien Wecker, MSN, MA, RN, MHFA, CMI(c), International Clinical Success Manager at Micromedex, by Merative
Optimising medications with regular reviews
Polypharmacy isn’t intrinsically bad. Some people need to take multiple medications to manage their conditions and many people do so safely. Age UK, a charity dedicated to supporting elderly people, however recently estimated that approximately one in five prescriptions for elderly people living at home may be inappropriate.6 In the light of Age UK’s finding, it seems that the rates of problematic polypharmacy are on the rise and older people are among the groups most impacted.
Regularly reviewing the medicines prescribed to vulnerable patients is one of the best ways to identify and prevent harm early. As a clinical intervention approved by the National Institute for Health and Care Excellence (NICE) in the UK, a Structured Medication Review (SMR) provides clear guidance to clinicians on how to engage with patients to discuss their medications, reduce the risk of harm and improve quality of life.
“Turning the tide on overprescribing starts with the patient. Our core focus shouldn’t be cutting the number of drugs, but ensuring people are taking the appropriate medicines to improve their lives and outcomes by aligning care with the goals that matter most to our patients.”
– Lelly Oboh, Overprescribing Lead Pharmacist at South East London ICS
As Lelly Oboh rightly points out, effective medication reviews put the patient first. With a holistic understanding of a patient’s lifestyle, circumstances, and goals, we can better align their medications to suit their needs and, ultimately, help to improve quality of life.
In my clinical practice, I tried to always ask patients if there is one particular side effect or health challenge that they are aiming to alleviate that could significantly improve their quality of life, and then I work my evidence-based clinical decisions around that goal.
Achieving best practice with trusted tools
When we place patients at the centre of medication reviews, we can put prescribing templates and evidence-based guidance from Clinical Decision Support (CDS) tools to the best possible use. And having access to a CDS solution that can provide timely, trusted guidance at the point of care is vital to reducing avoidable harm. But what makes a good CDS tool stand out?
Making sure that your reference solution takes information from well-researched, established and peer-reviewed sources is an important factor. With accurate information approved by the medical community, we can have confidence that our decisions are underpinned by the latest research and evidence on any given medicine or condition.
Clear warning systems that alert us to potential dangers are also incredibly valuable, particularly from the perspective of reducing avoidable harm. When treating elderly populations, consider selecting tools that incorporate the Beers Criteria for potentially inappropriate medication use in older adults, and the STOPP/START criteria for the appropriate use of medications in elderly patients to support guidance around reducing problematic polypharmacy and avoiding unnecessary or inappropriate medicines.
Warnings that point out when medications may sound or look similar to another medication can also help us to prevent prescribing errors. Similarly, tools that incorporate ‘do-not-crush’ information are particularly important when treating elderly patients who may receive medication through a feeding tube. This is because the dosage and absorption rate of certain drugs can change dramatically when they are ground into food
Equipped with the right tools and a comprehensive understanding of the needs of elderly patients, clinicians will be much better placed to reduce problematic polypharmacy, cut the risk of avoidable harm, support more cost-effective medication usage and, crucially, improve patient outcomes.
Did you know? Micromedex is an evidence-based clinical reference tool that supports patient safety around avoidable harm.
To find out how it is helping healthcare professionals to reduce the risks of polypharmacy in older populations, take a look at the datasheet below.
- British Medical Journal (BMJ), “Around one in 20 patients are affected by preventable harm”, BMJ Newsroom, July 17th 2019, https://www.bmj.com/company/newsroom/around-one-in-20-patients-are-affected-by-preventable-harm/ll. (last accessed July 2023)
- Dr Keith Ridge, Good for you, good for us, good for everybody: a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions (London: Department of Health and Social Care, UK Government), 74, https://www.gov.uk/government/publications/national-overprescribing-review-report.
- Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016 Apr;176(4):473-82; https://pubmed.ncbi.nlm.nih.gov/26998708/
- Dr Keith Ridge, Good for you, good for us, good for everybody: a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions (London: Department of Health and Social Care, UK Government), 20, https://www.gov.uk/government/publications/national-overprescribing-review-report.
- Haque, R. ARMOR: a tool to evaluate polypharmacy in elderly persons. Annals of Long-term Care. 2009; 17(6):26-30; https://www.cse.msu.edu/~cse435/Handouts/EMR/Polypharmacy-ARMOR.pdf.
- Age UK, More harm than good: why more isn’t always better with older people’s medicines (London: Age UK, 2019), 3, https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/health--wellbeing/medication/190819_more_harm_than_good.pdf