How to reduce medication errors in patients over the age of 65?

KEYWORDS:

• Patient safety
• medication errors
• elderly
• pharmacist role
• quality assurance

1. Why does it matter?

Medication errors (MEs) refer to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer [1]. MEs are one of the most frequent causes of preventable adverse events [2,3]. They can occur as a result of errors in drug package design, during prescription, dispensing, distribution, or at the time of administration. Although most ME studies have looked at what happens while the drug is in professional hands, patients in the home also make mistakes when storing and administering medications [4,5]. MEs are more common among patients with two or more chronic conditions, which usually coincides with increased age [6,7]. Many older patients are aware that MEs can occur at any time [8,9].

Medication without harm constitutes the World Health Organization’s Third Global Patient Safety Challenge [10]. The safe use of medication at home is also a part of this challenge. In developed countries, particularly, policies aimed at safe drug use, the gradual aging of the population, and the growth in the number of older people living alone and suffering from various chronic conditions must be considered. In developing countries, low health literacy is related to MEs. All factors are known to contribute to MEs at home [4]. Health authorities, policymakers, health managers and planners, the pharmaceutical industry, clinicians, and patient associations should intervene in a coordinated manner to reduce these MEs.

MEs’ frequency and causes are known when medications are in the control of the healthcare professionals. It is time to pay more attention to MEs that occur in patients’ homes and to extend interventions also to when medications are in the control of the patients.

2. What do we know?

2.1. Frequency

The frequency of adults’ patients making MEs has been estimated between 19 and 59% according to the complex therapeutic regimen, increasing up to three-quarters of patients over the age of 65 years have one or more MEs over the course of a year. About 4% added up to four or more medication errors in the same year. Approximately one-third of insulin-dependent patients, and of those who use inhalers, make four or more MEs annually. It is even greater when this patient is dependent on a caregiver. These figures exceed what doctors expect to happen [4].

2.2. Types

Incorrect dosage, mixing up medications, confusing one drug with another because of the color or shape, forgetting, failing to correctly recall the doctor’s indications, taking out-of-date drugs, ceasing of treatment when feeling better, chewing when the drug should be swallowed or swallowing when should be chewed, or taking medicines that have been inappropriately stored [4–6].

2.3. Causes

Low levels of health literacy, follow a complex therapeutic regimen, barriers in communication with healthcare providers, inconsistencies in information provided by professionals, lack of information on precautions to be taken when taking medication, misinterpreting or forgetting the doctor’s/pharmacist’s indications, use of herbs or other natural products without telling one’s doctor, frequent changes of doctor or inconsistencies between messages from various healthcare providers about the same health condition, being cared for by several teams of professionals with little coordination between them, depending on several caregivers, administering medication through devices that require direct intervention by the patient or their caregiver to calculate the correct dose, not knowing what the medication is being taken for, and the iso-appearance in the presentation of the medication [4–6,11,12].

2.4. Consequences

One-quarter of adverse drug reactions have been linked to patient errors [4,13]. The inappropriate use of analgesics, cough/cold medications, cardiovascular agents, insulin, antihistamines, and antimicrobials led to a greater number of adverse events. This is probably because the majority of errors have no physical negative consequences for patients, and little attention has been paid to this problem. However, it must be considered that in some cases, they require a new treatment that in a few cases includes hospitalization (approximately 5% of errors) [14]. Most of them raise concern for the patient and their relatives, consumption of health resources (new consultations), and unsafe in the course of treatment that incites commission errors.

3. How it has been handled up to now

An analysis of what works and what does not prevent MEs performed by patients at home. Ideas that have been implemented so far include the following:

Information on brochures, websites, and blogs to help prevent errors. Although it is not frequent information, some websites include examples not to confuse eardrops and eyedrops, avoid chewing unchewable medication, or how to use the right spoon. The redesign this information supports, should not be ruled out, considering the preferences and needs of older people. It is necessary to consider that age does not necessarily have limitations. The size of the letter or the ability to understand written information (regardless of age) seems to limit the degree of understanding of the information.

There is an increasing number of websites with specific recommendations to increase the safe use of medication at home, such as: verify that it is the drug prescribed by the doctor, make a medication list, keep your medication list up to date, store medications in their original containers, tell your provider about any vitamins, supplements, and over-the-counter products you take and list them with the medications.

Another line is to make changes in the format and packaging of medications to make them look different [11,15]. Packaging should be sufficiently clear and contain basic information for patient safety, including the correct route of administration and assuring when applicable that generic medicines using the same active ingredients as brand-name medicines are functioning in the same way. The tall man lettering is a simple idea that avoids confusion as it helps to better identify the medication in the packaging.

Work is constantly underway to redesign dispensing devices. Recently attention has been given to the redesign of syringes, cups, spoons, and inhalers for ease of use and safety. The experience of patients using these devices is key to achieving effective changes.

Patients receiving multiple medications to treat multimorbility, often with overlapping indications, are receiving attention and interventions to promote the appropriate use of medications. Among them, digital-based interventions have increased recently [16,17], although it does not yet address the usual MEs in the home. Since polypharmacy is causing burden and harm in the elderly, and is one of the factors related to MEs, a deprescribing (planned and supervised process of dose reduction or stopping of medication that might cause harm, or no longer be of benefit) guide by multidisciplinary providers teams [18] is another way to reduce the number of MEs in homes.

Different campaigns have been launched to activate the patients into gaining knowledge regarding MEs. Increasing patient health literacy, encouraging patients to know more about their medication and asking questions (especially when changing their medication or dosage), and being an active agent in their self-care are key elements in reducing MEs at home [4,19]. Providing written information and advising patients to keep a record of medications and their dosage, especially in the case of patients who are in the care of several people, is another common advice that possibly contributes to reducing MEs [6]. Interventions aimed at empowering patients in the correct management of medication have yielded better results [20]. In this regard, information campaigns have been devised on the role of patients in the safe use of medication, reinforcing its role as a final barrier to adverse events [21]. Research focuses on medication management to provide data on what interventions work and their key points [22].

New alarm and medication control devices. Dispensing devices (pillboxes), in their different forms, contribute to reducing MEs [4,6]. Currently, these devices have been modified to make them compatible with the use of smartphones and tablets [23]. mHealth solutions designed to increase adherence are expected to contribute to reduce the number of MEs in homes [24].

4. What else could be done?

The most common mistakes, causes, and consequences have been studied. However, the information collected was not systematically used to prevent these errors. Because older people most often suffer from more than one chronic condition and follow several treatments at once, they are the most likely to experience MEs. Until now, efforts to avoid these errors at home have been too isolated and far removed from patient safety policies. This should be changed to meet the WHO’s challenge of medication without harm.

We could also put into practice some other ideas, such as involving the patients (or caregivers) in both deprescribing and conciliation in all the transitions to ensure that all the medications they are taking are considered [25,26]. Medication packaging products must also be considered. Visual apparency of medicines and tailoring packaging types and technology to patients’ and caregivers’ preferences (for example, considering their preferences for larger font size [27]) could contribute to reducing mistakes. Learn from their homemade tricks to avoid MEs (e.g. ordering medication at home based on dosage, associating mealtimes and snack times with their medication, writing the dosage on the box itself, or leaving it in full view in the living room). Specific interactive interventions could include issues regarding common mistakes at home of patients with multimorbidity and polypharmacy, increasing safety.

Train professionals to be aware of the possibility of MEs occurring when the medication is in the hands of the patient or their caregivers. The role of pharmacists adds value to interventions for increasing safety (for example, warning patients about risks, identifying troubled patients with medication management) and participating as members of the health care team in deprescribing, and conciliation to reduce the complexity of treatment regimens [28]. Renewed efforts should be made considering the benefits of these interventions by reducing the possibility of errors in the home. Given that adherence improves when the relationship with the community pharmacy is more fluid [29], it should be explored whether it also contributes to reducing MEs in the home.

With the growth of blogs, discussion groups of forums, newsgroups, and wikis, patient schools’ platforms exchanging ideas to learn each other could be impacted by the differences between the credibility and reliability of drug information on the Net. In addition, highlighting the dangers of stockpiling drugs at home or recommending that distractions, or doing two things at once, increase the number of MEs, for example, when preparing and administering medication for two patients at once. Along the same lines, it is necessary to see which electronic devices (such as electronic pillboxes, conversational assistants such as Alexa, Siri, Google Assistant) work and why, and to prove [17,30] their performance so that the public knows what to look for when choosing one of these devices.

The literature agrees that informing patients is insufficient [31]. Patients should be encouraged to participate actively. The easiest thing is to listen to them, and even then, it is not always done [32]. The following is to allow them to participate in the design of proposals that help other patients avoid MEs at home.

Reducing MEs in patients over the age of 65 is a challenge that combines to achieve greater effectiveness and safety in treatments to which health systems, institutions, and clinics, together with patient associations, should respond urgently. The prevention of MEs that the elderly make at home should be an undeniable priority for patient safety policies. However, we only have results from studies that have already addressed how to reduce these MEs in their homes, without a targeted policy to implement the ideas derived from these results. National patient safety strategies do not yet address their impact on patient safety. It is time to change the situation, involving policy makers and healthcare authorities to identify specific targets to address the challenge of Medication without harm.

5. Expert opinion

5.1. Key findings

Research has pointed out the frequency of MEs made by patients at home. Healthcare providers must consider that their patients have many more opportunities to make MEs than is generally believed. Approximately 75% of patients over the age of 65 years make yearly MEs. This figure is too high to be ignored, although the consequences of a majority of these MEs are mild.

The current mHealth solutions have opened up new possibilities for interventions to prevent mistakes in the home. There are many new ideas, but the number of patients who have participated is small in most cases. Diversity offers opportunities but does not translate into products that can be made available to a large target audience.

5.2. Weaknesses in research

Attention continues to be paid to MEs that occur while medications are in the hands of healthcare professionals. A majority of research remains focused on what is happening in health centers, and what is occurring in the homes is hardly analyzed. Although we have information that would enable us to act, we do not proactively help patients avoid these errors at home. Nor do we usually listen to what patients have to say. Patients and their relatives can contribute to increased patient safety. Pharmacists can play a crucial role in collecting patients/caregivers’ views and experiences and sharing this information with the healthcare team.

MEs should be reduced by designing packaging that eliminates mistakes, collecting all relevant information from patients, assuring the quality of the information given to the patients, and remembering to take the right medication and the correct way to use the medication. However, we do not know what works best to avoid mistakes at home and what interventions should be prioritized to generate an appropriate framework for safe use of medication at home for specific patient profiles.

Studies focused on adherence to therapeutic regimens have also highlighted how simplified dosing, counseling, and patient education had positive effects on the capacity of patients to use of the medication correctly, which translates into better health outcomes [33]. However, this research is usually disconnected from key questions regarding safer medication challenges. The more frequent causes of MEs when medications are in the control of the patients are usually not included in the interventions designed to increase adherence.

The role of formal and informal caregivers in the elderly is crucial. However, the research has not provided sufficient data about what interventions are more efficient for them. It includes defining the roles of patients and caregivers in deprescribing approaches.

The inefficiency due to unsafe medication use at home is unknown. However, this figure could be aware of policymakers’ interest in this issue, for example, developing a more demanding regulatory framework in terms of safer naming, labeling, and packaging of medications.

Although low health literacy has been identified as a precursor of MEs in the homes, there is not a systematic assessment of the effectiveness in the reduction of mistakes of the interventions designed to enhance patient’s health literacy. Sharing the expertise that other patients are using to avoid common MEs at home could be an effortless way to increase patients’ ability to make better use of medication. This is particularly relevant in countries where the health literacy of the general population is upgraded. In this sense, we need information on whether pictorial information in medication instructions is better than written instructions alone and for what cases.

The WHO has identified other priorities for research in the context of the Medication Without Harm campaign [34], such as patient involvement in speaking up when they see the potential for medication-related harm, or the algorithm developed to help healthcare providers identify individuals who are at risk of serious medication-related harm.

5.3. What knowledge is needed, and what is the biggest challenge being achieved?

Patient (or informal caregiver) empowerment should be the ultimate goal of research in this field. The patient took their medication daily, combined medications, foods, and herbs, followed or forgot what they were told at the doctor’s office or pharmacy, and decided what doubts should be asked. Any research conducted to achieve safer use of mediation must involve them. Otherwise, it will be more difficult to achieve its purpose because in the equation, we must not forget that many medications depend on patients themselves to be effective and safe.

In future, we are likely to see a significant increase in mHealth solutions and new devices to improve treatment adherence and safe use of medication such as web-based medicine platform, mobile screening tools, mobile apps, smart pillboxes, or electronic automatic medication dispensing devices.

The pharmacist’s access to patient information will probably be extended once there is evidence of its benefits. In addition, an increase in the recognition of the role of pharmaceutical care (including pharmacotherapeutic follow-up) enhances the patient safety environment. This target includes the elimination of communication barriers among front-line healthcare providers (physicians, nurses, pharmacists, and other profiles that are being incorporated into the teams to deal with chronicity.)

Identifying what tools and interventions work on what patient profile, it is highly probable that this is another result that we will see. In addition, tools to support healthcare providers in helping patients with safer medication uses in their homes.

Meanwhile, we should look for ways to contribute to the medication without harm challenge, considering patients as a decisive player in the treatment outcome. Patients must play a key role when the packaging is designed, reviewing what information is needed, how this information should be translated to them, explaining how they address MEs, and being heard as the last barrier to prevent safety incidents related to medications.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was funded by the PROMETEU/2017/17 research Project on mHealth solutions for patients suffering chronic conditions funded by the Consellería de Educacion, Investigación, Cultura y Deporte de la Generalitat Valencian (Spain).