Medication errors in the older people population

KEYWORDS:

• Quality assurance
• patient safety
• medication
• elderly
• drug safety

Adverse events (AEs) related to medication are the most frequent safety incidents among the older people [1–3] mainly because three of the main causes of these incidents coincide: old age, multiple pathology, and polypharmacy [4,5]. While adverse drug reactions are considered the most frequent unavoidable AEs, professional errors in prescribing, preparation, dispensing, and administration have been analyzed as direct causes of avoidable AEs [6]. But this description is incomplete whether we do not consider the medication errors that patients, or their caregivers, make when preparing or taking medication at home [7,8].

Between 75% and 96% of older patients acknowledge that they frequently make mistakes with their medication [9–12]. They are also the ones who make the most telephone inquiries to the national poisons’ information service due to medication errors [13,14]. Despite of this, there is not the same interest in medication errors made by patients at home. A majority of studies about medications errors have been focused on the AE or near misses due to professionals’ decisions, behaviors or attitudes [6,15–17]. The study of medication errors made by patients at home must be also included in the focus of the research on patient safety.

It is obvious that a correct diagnosis and a correct prescription will not have the expected effect if the patient, once at home, takes the medication in an incorrect way. The figures of medication errors among older patients invite us to reflect on whether we should systematically incorporate strategies to improve therapeutic adherence, new initiatives to reduce medication errors in the home.

A medication error has been defined as 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 [18,19]. In the studies carried out so far, the frequency, causes, and consequences of patient errors during self-administration of medicines at home have been approached from different methodologies [8]. Although there is no single definition of error in these studies, the tendency is to consider a medication error of the patient as the wrong use of a medication according to the prescription given.

Medication errors made by patients can be classified into: commission errors (for example: error in calculating the dose, repetition of the dose, doubts about how to use the dispensers correctly, taking the medication from another person or a pet, taking it once expired, storing it in inappropriate conditions, etc.); and errors of omission derived from not having the correct information, confusing instructions, and forgetting the doctor´s or pharmacist´s instructions (Table 1). These errors, in some cases, can lead to severe damage that requires a new pharmacological treatment, hospitalization or can have fatal consequences. Overall, we must expect an increasing complexity of clinical practice and major patients’ vulnerability both causing greater probability of mistakes at home.

Table 1. Medication errors made by the older population.

Patient medication errors^a Categories	Frequent errors	Approaches for tracking with errors
Commission	Dosing mistakes, incorrect dosage (higher dose), double dose. Administering a wrong medication due to look-alike packaging. Dispensers misuse. Taking the correct medicine but inappropriately combined with food, beverages or herbal substances. Taking the medication from another person or from a pet. Taking drug once expired. Storing in inappropriate conditions. Over-the-counter use.	Re-design the containers, presentations, dispensers and instructions considering the behavior of patients at home. Review iso-appearance of the packaging and presentations to avoid confusions. Promote the use of electronic pillboxes and other mHealth solutions to increase medication safety use of medication. Promote reconciliation of medication to reduce the burden of treatments. Review the information given, particularly in case of low health literacy. Patient Expert interventions: may include patient experience of medication misuse and effective home care tricks to tackle with. Do not forget to advise caregivers (relatives) of dosing and precautions to be account. Promote self-care engagement in drug safety. Promote debates on safety in virtual learning communities or networks of caregivers.
Omission	Forgetfulness. Incorrect dosage (lower dose). Forgetting the doctor´s or pharmacist´s instructions. Improper timing. Mistaken drug because of confusion or misunderstanding of the general purpose of the medication.

^aPatient medication error: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the patients (or their caregivers). Between 75% and 96% of older patients have declared that they frequently make mistakes with their medication [9–12].

Despite their frequency and impact, the interventions to reduce these medication errors of the patients have not been deployed with the desirable intensity among health organizations, the pharmaceutical industry, and professionals. There are two presumptions that limit these actions. Firstly, consider that these errors do not have great importance on the patient´s evolution. Secondly, these errors correspond to the patient’s personal or family sphere and, therefore, are not the responsibility of the health-care professionals. However, what happens in the domestic sphere is also an area of competence of health organizations and their professionals and the research carried out so far has proven, for example, that the similarity in the presentation of different drugs, the presentation of the information on the package leaflet, the complexity of the therapeutic regime (number of drugs and daily doses), frequent changes in the prescription for the same pathology, the number of doctors of different specialties that attend to the patient, the information provided by the doctor on the safe use of the medication or the use of pillboxes or other household tricks, bear a direct relation on the frequency of these patient errors [11,20–25].

It has been proven that errors can be aggravated when there are several people involved in the patient´s care or if the information is not standardized among this set of caregivers [26], that the more known about the medication being taken, the greater the reduction in errors [21] and, that the information on the leaflets does not address with sufficient clarity the precautions that, based on the patient experience, should be adopted in the home for a safe use of the medication [27]. However, older patients (and particularly if they have several caregivers) do not know enough about the medication they take, do not have the appropriate help to avoid errors and the information they receive (usually dosage and frequency) does not address issues key to safe use of the drug once they are at home [28,29].

Informing the patient is not enough. Informing does not imply that the patient has all the necessary information at home. Nor that the patient can follow those indication at home. Improving verbal and written communication with patients (and their caregivers) could help to minimize errors, but it is not only the responsibility of first-line professionals to contribute to reducing these errors. To avoid these errors, actions should be carried out from the health-care organizations, the pharmaceutical industry, the patients themselves and, when they are done, their caregivers.

The results of research on the causes of patient errors and their tricks and ideas to avoid them put us on the track of some interventions that we could implement. For example, the industry and the drug agencies could consider the iso-appearance of the packaging and presentations and the medicines. If they are the same, then make them look the same and if they are different, then make them look different [30]. They should also consider the behavior of patients at home when designing the containers, presentations, dispensers, and instructions and, among their recommendations, also include advice on which type of pillboxes are most appropriate according to the different therapeutic regimes. The treatment burden that supposes the daily taking of medication for the patient has been directly associated with the probability of committing errors in the home [31]. So, health systems should reflect on the differences between organizational models and practice styles that affect the average number of drugs that older people must take daily [32]. The different number of doctors and nurses who care for the patient also has a direct effect on this burden and on medication errors at home, especially when the instructions are contradictory [8]. The figure of the patient’s reference person and the reconciliation of medication could be prioritized among people with a lower educational level, in whom a greater polypharmacy and probability of errors are concentrated [22]. The role of health apps, telemonitorization, and new technological developments such as electronic pillboxes may also change how adherence is assessed and assured [33,34].

Some promising ideas to improve safety at home are extracted from the results of the research. Health literacy has a protective effect in terms of the number of errors [35], so the goal of increasing this literacy could be part of patient safety strategies for health organizations. Patients can be excellent allies to avoid these medication errors by teaching other patients their own tricks and what they should pay attention to, in order to achieve a safer use of the medication. The ‘expert patient programs’ could incorporate this type of content and those participating in expert caregivers’ programs should be introduced into the debriefing technique for those cases where several caregivers take turns in caring for the same patient. Self-care engagement could reduce medication errors in the home [36]. This implies that in addition to taking care of the information given to the patient, it is necessary to look for alternative methods for transmitting information in the doctor´s surgery to achieve better results [37]. In our current care and information protocols, there is not enough insistence on the patient´s involvement and it is necessary to check that the patient has understood the dosage indications and the precautions when taking the medication (with or without food, to exclude certain types of foods, what drugs should not be mixed, etc.). Experiences in reporting safety incidents by patients have not usually contemplated the possibility that these notifications include errors in the home to help other patients to more safely use the medication[38]. The active participation of patients and caregivers could help improve processes and prevent future errors. The use of virtual communities or networks of caregivers, where those interested can consult doubts and receive instant answers, for example, through virtual assistants represent alternatives that we are beginning to explore. Older patients who use pillboxes, traditional or electronic, and who resort to household tricks to improve their adherence (annotations in the containers, prepare the medication for the week on Sunday, etc.) are those who best manage to avoid these errors [39–41] but there are other patients in whom most of these errors are concentrated (and they are usually errors that have more serious consequences) without having enough knowledge to stratify patients considering the risk of error nor have evidence of which are the most effective interventions in each case.

The volume of medication errors constitutes a severe public health problem, and, among the older people, it is a priority that invites to promote an alliance of the actors of the therapeutic process to offer an optimal quality of care. Health authorities, the pharmaceutical industry, medical professionals, nurses and pharmacists and, patient associations should include the objective of reducing medication errors in the home in the radar of their interventions.

Declaration of interest

The authors have 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

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

Additional information

Funding

Consellería de Educacion, Investigación, Cultura y Deporte de la Generalitat Valenciana. Reference PROMETEU/2017/173.