Outpatient Medication, Allergy,

1
Outpatient Medication, Allergy, Adverse Drug
Event Discrepancies in Ambulatory Care

• Presenter T. Patrick Jensen MS1
• Faculty Co-investigator Sponsors
• Mary Stephens, MD, MPH ETSU Family Physicians
  of Kingsport
• Beth Fox, MD, MPH ETSU Family Physicians of
  Kingsport
• Gary Kukulka, PhD Research Division, Family
  Medicine

2
Definitions

• Medication Discrepancy a medication listed in a
  patients medical record differs from what
  patient is actually taking.
• Allergy Discrepancy when prior or known
  allergies or Adverse Drug Events (ADEs) are not
  documented on the medical record.
• Adverse Drug Event a response to a drug that is
  unexpected, unintended, uncommon or previously
  unreported.

3
Definitions Cont

• Medication Variance any preventable event that
  may cause or lead to inappropriate medication use
  and/or patient harm.
• Medical Error the failure of a planned action
  to be completed as intended.

4
Specific Aims

• Determine the frequency of medication and
  allergy/ADE discrepancies in the medical record.
• Describe patient characteristics associated with
  any discrepancy.
• Illustrate correlations between physician status
  and medication discrepancies.
• Develop intervention research based on the study
  results.

5
Review Rationale (Medication Variables)

• low perceived importance of prescribing as one
  criteria among others for medical errors3
• discrepancies in 76 of medications when
  comparing medication records and bottle review6
• 59 discrepancies involved patients taking
  medications not recorded.
• 20-30 of dosage discrepancies

6
Review Rationale (Medication Variables)

• Studies classified the different stages of
  medication errors reporting the frequency of
  each1,3,5,20, 21, 24
• Prescription Errors - 56 57
• Administration Errors 34
• Prescription-writing errors 19
• Transcription Errors 6
• Dispensing Errors (Duplication) 4
• Monitoring Errors

7
Review Rationale (Medication Variables)

• Reported 18 of patients in an outpatient setting
  with ADEs.
• Approximately 16 of prescriptions to elderly
  patients met the criteria for suboptimal
  combinations or inappropriate prescriptions.23
• Ambulatory elderly, reported that at least 1
  potentially inappropriate psychotropic agent was
  prescribed in 27.2 of all visits.18
• Inpatient-outpatient continuity reported that 49
  of the transitory patients experienced at least
  one medical error.

8
Review Rationale (Patient Variables)

• Medication discrepancies related to various
  patient attributes
• use of cardiovascular drugs2,23
• difference in primary language7
• Race9,17,18,21
• Sex9,17,18,21
• Insurance coverage9,17,18,21
• Age2,9,17,18,21
• Number of medications2,17
• Last or recent hospitalization17

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Review Rationale (Physician Variables)

• A study observing patient office medication
  review and practice reported that12
• 68 of physicians reported to have recorded OTC
  medications on the MR.
• 63 recorded nutritional supplements
• 47 recorded herbal or alternative treatments
• The same study reported that12
• 86 of physicians reported reviewing OTCs before
  prescribing a new therapy
• 45 reported reviewing herbal treatments before
  prescribing a new therapy
• 42 reported reviewing alternative treatments
  before prescribing a new therapy.

10
Review Rationale (Physician Variables)

• Various studies have observed the following
  criteria for physician variables associated with
  medication errors
• Physician age9
• Physician speciality9
• Visit with primary care physician or not9
• Number of tests pending at discharge17
• Number of outpatient work-ups suggested in
  inpatient medical record17
• Time from discharge to outpatient PCP visit17
• PCP status17
• Inpatient-outpatient PCP continuity17

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Review Rationale (Interventions)

• Suggested and observed interventions include
• Education and knowledge about medications (both
• patient and physician)7,22
• Use of a PDA10
• Computerized Physician Order Entry20,25
• Electronic Medication Record1,25
• Bar coding1,2
• Including a clinical pharmacist on rounds1,16
• Home Medication Reviews8
• Systematic review of medication bottles2

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Research Design Methods

• Overview examine medication frequencies,
  allergies, ADE discrepancies and demographic
  data.
• Data Sources medical record and structured
  patient interviews.
• Study Population a primary care outpatient
  clinic in Kingsport, TN.

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Research Design Methods

• Data Sources and Variables of Interest
• The patient variables are (see Appendix A)
• Gender
• Age
• Last hospitalization
• Primary language
• Insurance status
• Education
• Presence of cardiovascular disease
• The Physician Variable studied will be the PCP
  status

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Research Design Methods

• Instrument See Appendices A-D
• Process
• Participants in the study must be 18 years or
  older and have had at least one prior visit to
  the clinic.
• Prior to the appointment time, patients who meet
  eligibility will be contacted by an appointed
  staff member by telephone.
• The patient will then be informed concerning the
  study. They will then be asked to bring all of
  their medication bottles.
• Prior to their appointment time, they will meet
  with a research assistant who will spend
  approximately 15 minutes reviewing their current
  medications and prior ADE information.
• They will also be asked to provide some
  demographic information.

15
Research Design and Methods

• Implications and Future Plans
• This study could serve as a basis for future
  interventions to reduce medication discrepancies
  and identify high-risk patient populations for
  medication errors.

16
Preliminary Data Physician Review (N11)
17
Preliminary Data Medication Review (n1)

18
This work was supported in part by a grant from
the Bureau of Health Professions Health Resources
Administration, awarded toEast Tennessee State
UniversityJames H. Quillen College of
MedicineDepartment of Family Medicine Grant No.
1 D 16 HP00145 01.Additional research support
is provided by the East Tennessee State
University, Research Development Committee,
awarded toMary Stephens, MD, MPH Principal
Investigator Grant No. RDC 05-009M