Quality Improvement Report
Medication management for elderly patients in an academic primary care setting: A quality improvement project Maria V. Vejar, RN, DNP, GNP-BC (Nurse Practitioner)1 , Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, FAAN (Associate Professor)2 , & Ernestine Kotthoff-Burrell, PhD, APRN, FAANP (Assistant Professor)2 1 2
Division of Geriatrics, School of Medicine, University of Colorado, Aurora, Colorado College of Nursing, University of Colorado, Aurora, Colorado
Keywords Adverse drug events; allergy; geriatric; medications; safety. Correspondence Maria V. Vejar, RN, DNP, GNP-BC, Division of Geriatrics, School of Medicine, University of Colorado, 1635 Aurora Court, 5th Floor, Seniors Clinic, University of Colorado Hospital, Aurora, CO 80045. Tel: 720-848-3416; fax: 720-848-3401 Received: February 2013; accepted: May 2013 doi: 10.1002/2327-6924.12121
Abstract Purpose: Medication reconciliation is a National Patient Safety Goal. Completing medication reconciliation minimizes the risk for preventable adverse drug events (ADEs). The elderly are at greatest risk for ADEs because of their high number of comorbidities and medications usage. The purpose of this quality improvement project was to improve medication management in a geriatric primary care practice. Interventions focused on improving medication reconciliation documentation, improving accuracy of medication lists, reducing inappropriate medication use, and minimizing duplicate medication therapy. Data sources: A pre/post design was used over a 9-month period. Interventions focused on educating providers, staff, and patients on medication management. Analysis of 1580 manual chart audits and 903 patient questionnaires were completed. Conclusions: Outcomes improved in all four performance outcomes: medication reconciliation—χ 2 (1, N = 576) = 32.00, p < .0001, V = 0.4; patients bringing medications to clinic—χ 2 (1, N = 277) = 90.46, p < .0001, V = 0.7; reduction in use of specific medications—χ 2 (1, N = 267) = 19.49, p < .0001, V = 0.3; and duplicate therapy was reduced—χ 2 (1, N = 267) = 45.13, p < .0001, V = 0.5. Implications for practice: Improved medication management had a significant impact in patient safety and quality of care in this clinic.
Background knowledge Medication management and safety is a nationally recognized health issue. The Joint Commission (JC) has chosen medication management and reconciliation as one of its primary National Patient Safety Goals (Joint Commission [JC], 2011). Medication management is the process of educating both patient and provider on the safe usage of prescription and over-the-counter (OTC) medications. This process includes medication reconciliation, which involves compiling and using an accurate list of all medications the patient is taking (Institute for Healthcare Improvement [IHI], 2011). In addition to a fully reconciled list of medications, another goal is for the patient to understand why each medication is being taken, and the potential adverse reactions he or she may experience with the specific medication(s). C 2014 American Association of Nurse Practitioners
Although medication reconciliation is a requirement by JC, there are challenges in successfully implementing the process (IHI, 2011). Some difficulties in completing medication reconciliation include the following: lack of a standardized process, time restraints, patients not fully aware of all the medications they take, inaccuracies in the medication list, and often a focus on documentation rather than completing the process (IHI, 2011). The cost of not completing medication management is significant. Results from a recent study estimated 8000– 12000 deaths per year related to adverse drug events (ADEs; Shepherd, Mohorn, Yacoub, & May, 2012). Individuals aged 75 and older were found to be at higher risk for ADEs (Shepherd et al., 2012). Another study found many discrepancies between the actual medications the patient was using versus the medications the provider recorded as being taken. (Cumbler, Wald, & Kutner, 2010). 1
Medication management for older adults
In particular, ADEs are a significant concern in the elderly population because of their high number of comorbidities and medications usage (Gray & Gardner, 2009). It is estimated that treatment for medication errors and ADEs is in excess of $880 million per year for older adults (Institute of Medicine, 2006). The Beers criteria is a resource to assist providers in identifying and avoiding potentially dangerous prescription and OTC medications used by seniors (American Geriatrics Society 2012 Beers Criteria Update Expert Panel [AGS], 2012). These inappropriate drugs place the older adult at greater risk for ADEs (AGS, 2012).
M. V. Vejar et al.
and naproxen; (d) if it was determined that a problem with duplicate drug therapy existed, a reduction in the use of the duplicate medications and potential drug–drug interactions was desired. This QIP was patient-centered, with a focus on quality and safety issues. It was designed to be a collaborative effort to include all members of the senior’s clinic team. The quality improvement (QI) team consisted of care team assistants, medical assistants (MAs), registered nurses, a social worker, pharmacists, clinic providers (physicians, a nurse practitioner, and a physician assistant), and administrators. A geriatric nurse practitioner was identified as the team leader for the project.
Local problem A systems assessment of a ”senior’s clinic,” the practice site for this project, revealed that medication reconciliation was far below the JC national standard of 90% (JC, 2011). The clinic medication reconciliation rate was 53% in March 2011 (D. Franco, personal communication, March 3, 2011). Because the failure to conduct regular medication reconciliation is a serious issue that may result in potentially life-threatening consequences, a quality improvement project (QIP) was launched to address the gap in practice.
Intended improvement The QIP began with the intention of raising the rate of medication reconciliation to the national standard of 90% or higher over 1 year. Efforts were made to establish new behaviors where patients would bring all their medications to each clinic visit, including OTC medications. As the QIP progressed, the focus expanded into a broader sense of medication management, which included reducing the use of specific OTC medications and duplication of medications. The primary aim of this QIP was to decrease the risk for potentially preventable ADEs caused by drug–drug interactions, medication duplication, and the use of potentially inappropriate medications for the elderly through improved medication management and medication reconciliation. Four specific aims were defined to measure the success of this QIP: (a) Improve the rate of medication reconciliation from 53% to 70% within 6 months and reach a target of 90% within 12 months; (b) implement a process for patients to bring all their medications (including OTCs) to their scheduled clinic visits, starting with a benchmark of 0% to a goal of 75% within 12 months; (c) reduce the use of four potentially dangerous OTC medications, specifically diphenhydramine, Tylenol PM (which contains diphenhydramine), and nonsteroidal anti-inflammatory drugs (NSAIDs), specifically ibuprofen 2
Methods Ethical issues This QIP followed principles of QI and did not require Institutional Review Board approval. An external review of the project proposal was completed by the University of Colorado’s College of Nursing Doctorate of Nursing Practice COMIRB approval committee to ensure the project aims and intended interventions were consistent with QI. Minimal risk to patients was involved, as the process for medication management was part of an established standard of care. Confidentiality was maintained by de-identifying data and maintaining the data in a password-protected computer; questionnaires were kept in a locked cabinet.
Setting The senior’s clinic is a primary care practice located within a large academic setting in the mountain region of the United States. The average age of the patient population is 81 years, with a range of 51 years to 102 years. The senior’s clinic main focus is providing high-quality, comprehensive, evidenced-based care to patients while teaching students in the various academic programs on campus. At the foundation of this QIP was the concept of change. Lewin’s ”change theory” provided the theoretical framework to guide this project (Lewin, 1951). Lewin advised change should not be focused on reaching a specific goal but rather transitioning from the present level to the desired level. The concept of group dynamics was specifically addressed by Lewin, and this related directly to this QIP, given that the senior’s clinic is an interprofessional practice consisting of one geriatric nurse practitioner, seven physicians, one physician assistant, and three MAs.
M. V. Vejar et al.
Planning the interventions and study of the interventions Baseline performance data were obtained from the clinical information technology department providing the clinic’s current compliance with medication reconciliation. A root cause analysis was completed to identify potential causes for the low compliance rates. The two primary findings were that providers forget to document medication reconciliation in the appropriate location and patients were not fully aware of what their active medications were. Initial interventions were developed based on these findings. This QIP utilized a pre- and postintervention design. The preintervention time frame was from October 2010 to May 2011 and postintervention data assessment took place in June 2011–January 2012. Multiple interventions based on the literature, team feedback, and monthly reviews of outcome progress were implemented throughout the QIP. Open communication took place in both group and individual meetings with QI team members. Several Plan–Do–Study–Act (PDSA) cycles were completed for each specific aim in this QIP. Several interventions were implemented to improve outcomes 1–4; overall first to last observations for each outcome variable were measured. Benchmark data, 1 month of preintervention observations, were compared to the last month of observations, at the conclusion of this 1-year project. Individual impact of process improvement interventions were not measured as the QIP focused on processes to improve clinical practice outcome (e.g., outcome measures 1–4) The first goal of the project was to improve medication reconciliation documentation. Ten discrete and overlapping interventions were implemented over 11 months (see Table 1). Specific providers were identified as having difficulties with the electronic medical record (EMR) medication reconciliation process. Directed training efforts were provided for these providers in addition to the group as a whole. For each provider, data were collected through monthly EMR audits of clinic patients. Progress of this outcome was discussed in monthly team meetings. Interventions to achieve the second project aim focused on obtaining a comprehensive picture of all the medications that patients were taking to maintain an accurate active medication list in the EMR. An essential step of medication reconciliation is verification that providers are aware of all medications patients take, including OTC medications and natural supplements. Because bringing medications to the clinic was an important part of medication management, the planned interventions focused on educating clinic patients and QI team members about
Medication management for older adults
Table 1 Interventions for outcome 1: Improving medication reconciliation documentation Interventions implemented to improve practice with medication reconciliation documentation • Phone calls to patients reminding them to bring their medications to the clinic visit. • Placement of educational flyers for patients in exam rooms discussing medication management. • Patient questionnaires completed at check-in and check-out of clinic visit by care team assistants. • Provider education one-on-one and e-mails. • Provider reminder notes for documenting medication reconciliation placed in each exam room. • Educated new providers in clinic on medication reconciliation documentation. • Provider education given at faculty division meeting. • Intensification of provider education after transitioning to new EMR system. • Provider education both as a group and one-on-one at Division meeting and in clinic. • Automated reminder in EMR started in mid-October 2011. Table 2 Interventions for outcome 2: Increasing number of patients that brown-bag Interventions implemented to have patients “brown-bag” medication for clinic visit • Reminder phone calls to patients to bring medications to the clinic visits. • Patient questionnaires completed at the time of each visit, tracking if patients brought their medications to the visit and if the provider discussed the medications. • Flyers placed throughout clinic educating patients and team on “brown-bagging” medications. • Educated team members to remind patients of “brown-bagging” • Reminder phone message asking patients to bring all their medications to their clinic visit. • Follow-up patient questionnaires to assess how well the interventions were working. • Focused on improving support from MAs in patient education and data collection.
this process. The concept of “brown bagging” was introduced into the clinic practice. The process of brown bagging involves patients using a bag as a method of transporting all of their medications from home to the clinic. Table 2 outlines the series of interventions implemented to increase a comprehensive review of patient medications at each clinic visit. Data collection was completed through the use of a patient questionnaire that tracked if patients brought their medications to the visit. In total, 903 patient questionnaires were completed. Findings from earlier PDSA cycles revealed that when patients physically brought their OTC medications to the visit, many were using high-risk medications without the provider’s knowledge or consent. 3
Medication management for older adults
Table 3 Interventions for outcome 3: Reducing use of high-risk OTC medications Interventions implemented to reduce the use of OTC high-risk medications • Flyer placed in exam rooms with emphasis on high-risk medications and ADEs. • Educated patients to bring all medications, including OTC medications, to each visit. • Initiated a more detailed patient questionnaire to be used for data collection and followup. • Educated patients that OTC medications should not be considered safe. • Directed toward MAs involvement with patient education and data collection.
Table 4 Interventions for outcome 4: Reducing duplicate medication therapy Interventions implemented to reduce the use of duplicate medications • Provider e-mails to obtain recall information on patient duplicate therapy use. •· Pharmacist e-mails to obtain recall information on patient duplicate therapy use. • Patient questionnaires to collect data for duplicate therapy use. • Patient education on “brown bagging" continued. • Provider follow up regarding duplicate therapy.
The third specific aim of the study was to reduce the use of four potentially dangerous OTC medications, specifically diphenhydramine, Tylenol PM, and the NSAIDs naproxen and ibuprofen. It was unclear at the start of this QIP if this process outcome would be a significant issue in the practice. Interventions focused on identifying if clinic patients were taking specific OTC medications that were classified as being potentially dangerous based on the Beers criteria (AGS, 2012). Because OTC medications can be unsafe for patients if taken alone or with their other routine medications, PDSA cycles were planned to educate patients and family members of this danger. Table 3 provides a summary of the interventions to meet this study aim. The use of OTC medications was obtained by the patient’s self-report on the questionnaire. Based on patient questionnaire responses, providers educated patients on safe medication use (see Table 4). The last project aim explored duplication in medication therapy in the senior’s clinic population. Data were collected in two ways. First, provider recall was used to identify if providers felt duplication was an issue. Second, PDSA cycles tracked medication duplication based on patient questionnaires, review of medications brought to the visits, and EMR medication list evaluation. Figure 1 is a run chart demonstrating overall practice improvement for QIP outcome measures 1–4. 4
M. V. Vejar et al.
Results Each of the four outcomes utilized a pre- and postgroup analysis. EXCEL was used for data collection. SPSS version 19 and VassarStats (Lowry, 2012) were used for data analysis. VassarStats was used, since this statistical program weighs pre/post frequency data by sample size, to determine expected cell frequency. This program also allowed comparison of pre/post aggregate data using cell totals rather than individual lines of data. Descriptive statistics and chi-square analysis were completed on all four project outcomes. Cramer’s V was used to interpret the effect size from the results of the chi-square analysis. A quantitative data analysis for outcome 1 was completed with data from 1580 manual EMR chart audits. Outcomes 2–4 were analyzed using both predata and data from 903 completed patient questionnaires with matching chart audits.
Outcome 1 At baseline, the benchmark rate for successfully documenting medication reconciliation was 64% in the senior’s clinic. Chi-square analysis compared the preintervention compliance (64%) to postintervention compliance (96%) of medication reconciliation. Of these 576 data points, 360 chart reviews were in the preobservation period and 216 were in the postobservation period. The overall improvement in provider documentation of medication reconciliation for each clinic visit was found to be statistically significant (χ 2 [1, N = 576] = 32.00, p < .0001, V = 0.4). The Cramer’s V of 0.40 suggests a moderate strength of association between the interventions and outcome of medication reconciliation.
Outcome 2 Baseline data for the percentage of patients who brought all their medications, including OTC medications, to each clinic visit were 0%. Post intervention, 64% of patients brought all their medications to clinic visits. Of the 277 data points, 61 were in the preintervention phase of the QIP and 216 comprised the postintervention observation data. Data analysis revealed a statistically significant improvement in the number of patients who did participate in brown bagging for their clinic visits (χ 2 [1, N = 277] = 90.46, p < .0001, V = 0.67). For this outcome, Cramer’s V of 0.67 suggests a moderately strong association between the interventions and outcome of medications brought to each clinic visit. Descriptive statistics from the 903 patient questionnaires revealed the mean age 79.5 (SD ± 6.9) with 68.7% being women and 31.3% were men.
Medication management for older adults
M. V. Vejar et al.
120 100 80
% Medication Reconciliation
60
% Patients Bringing Medications
40
% OTC Usage
20
% Duplicate Therapy
0
Figure 1 Visual representation of the overall changes in outcomes 1–4 run chart.
Outcome 3 At baseline, 46% of patients reported using one or more high-risk and potentially dangerous OTC medications being tracked. Chi-square analysis compared the preintervention usage (46%) to postintervention usage (17%) of these higher risk medications. A total 216 charts were reviewed, in which 51 were in the preintervention data and 216 were in the postintervention data. Analysis of data revealed a statistically significant reduction in the use of these high-risk medications (χ 2 [1, N = 267] = 19.49, p < .0001, V = 0.31). Cramer’s V of 0.31 suggested a weak association between interventions and outcome of reducing the use of these potentially dangerous OTC medications. Descriptive analysis demonstrated the most commonly used OTC medications were NSAIDs accounting for 14.5% followed by diphenhydramine at 5%. Nearly 50% of the OTC NSAIDs being used by patients were not reflected in their active medication list, and 0% of diphenhydramine use was noted in the medication list.
Outcome 4 Benchmark data for provider recall regarding duplication therapy in clinic revealed 80% of providers and pharmacists felt duplication was a problem less than 25% of the time and 20% felt it was between 25% and 50%. For this analysis, there were 267 charts in which the preintervention group consisted of 51 chart audits and 216 postintervention chart audits. Baseline data revealed patients were actually using duplicate medication therapy 39% of the time and post data found duplication of
medication to be 1%, a 38% reduction. Medications more commonly found to be duplicated between OTC and prescribed medications were NSAIDs and sedatives. Chisquare analysis showed a statistically significant decrease in duplicate medication therapy (χ 2 [1, N = 267] = 45.13, p < .0001, V = 0.47). The Cramer’s V of 0.47 suggested a moderately strong association between the QIP interventions and the reduction in duplicate medication usage.
Discussion Education played a significant role in increasing medication reconciliation rates and patients brown-bagging medications. In addition, there was a notable decrease in patient use of high-risk OTC medications. Accuracy of medication lists improved throughout this QIP, and resulted in a decrease of duplicate medication therapy. See Figure 1 for a collective graphic representation of the results these outcomes. The most effective interventions found to improve the outcomes of medication reconciliation were reminder notes posted in each exam room and monthly discussions with the providers regarding the current compliance rates. The greatest challenge occurred at the time of transition to a new EMR, when medication reconciliation rates dropped to below 50%. Following this setback, individualized education was focused on the method of documenting medication reconciliation, resulting in increased compliance. The outcome goal of 75% was not met for patients brown-bagging medications. In retrospect, a goal of 75% 5
Medication management for older adults
was likely not reasonable, because patients did not regularly bring medications to their visits before the start of this QIP. The most effective intervention for increased brown bagging was the automated phone reminder system, which was adjusted to specifically ask patients to bring their medications to their clinic visits the following day. Brown bagging was an effective tool in improving accuracy of medication lists. The least effective intervention was the attempt to increase MA involvement with patient education. The MAs reported that this additional workload was difficult to add to existing responsibilities because of time restraints. This QIP identified an issue with the use of medications on the Beers list unknown to clinic providers. The most successful interventions included flyers posted throughout the clinic, and provider discussions following the completed patient questionnaires. The greatest challenges with interventions were attempts made to gain further participation with the clinic MAs with both patient education and data collection. This QIP identified a problem with duplicate therapy, primarily with specific OTC medications listed on the Beers list. Consistent with the previous two outcomes, interventions directed toward increasing MA participation were met with the greatest resistance to change from the status quo. The most successful interventions were those involving patient education on the dangers of duplicate therapy and the need for an accurate active medication list, which included OTC medications.
Relation to other evidence The topic of medication management is well documented in current literature. The results of this QIP are consistent with findings from several systematic reviews ¨ (Chhabra et al., 2012; Dimitrow, Airaksinen, Kivela, Lyles, & Leikola, 2011; Guaraldo, Cano, Damasceno, & Rozenfeld, 2011; Jano & Aparasm, 2007; Kaur, Mitchell, Vitetta, & Roberts, 2009; Marcum, Handler, Boyce, Gellad, & Hanlon, 2010; Peron, Gray, & Hanlon, 2011). Upon conclusion of this QIP, the clinic was in compliance with the JC National Patient Safety Goals on medication reconciliation, which is associated with improved patient care and outcomes (Chhabra et al., 2012; Guaraldo et al., 2011; Kaur et al., 2009). Improvements in medication management throughout this project increased accuracy of existing patient medication lists and potentially assisted with reducing preventable ADEs, consistent with existing literature (Chhabra et al., 2012; Guaraldo et al., 2011; Jano & Aparasm, 2007; Kaur et al., 2009; Marcum et al., 2010). The collaborative team approach used throughout this process was effective in improving medication management. These findings were similar to 6
M. V. Vejar et al.
those of Chhabra et al. (2012) and Kaur et al. (2009). Both senior’s clinic providers and pharmacists played instrumental roles in medication management, as reported in other studies (Chhabra et al., 2012; Dimitrow et al., 2011; Kaur et al., 2009). Tools, such as the Beers criteria, used to guide providers in minimizing the use of inappropriate medications for the older adults are supported in the literature (Guaraldo et al., 2011; Peron et al., 2011) and were found valuable in this QIP. Inappropriate prescribing for the elderly places these patients at greater risk for ADEs (Dimitrow et al., 2011; Guaraldo et al., 2011; Jano & Aparasur, 2007; Kaur et al., 2009; Marcum et al., 2010; Peron et al., 2011). A topic for future study is the consideration of OTC medications on the Beers list being self-prescribed by patients without the knowledge or approval of their providers (Chhabra et al., 2012).
Limitations One of the limitations was limited benchmark data, specifically for outcomes 2–4. Despite the number of interventions completed throughout this QIP, the actual effect of each intervention cannot be fully determined. Interventions for this QIP were based on the process and team dynamics of this senior’s clinic; thus the findings from the project may not be generalizable to other geriatric clinical practice settings.
Strengths Strengths of this QIP included an increased awareness among providers of the importance of improved medication management in this practice setting. Patients and providers both benefited from education regarding Beers criteria in reducing the use of some high-risk medications. Improved medication management enabled the senior’s clinic to reach the nation standards for medication reconciliation.
Conclusions The key findings of this QIP may be used to improve medication management in other settings. Clinicians should remember the importance of using a collaborative team approach with the patient being at the center. A team approach was effective in improving patient care and medication management in this practice setting. Improving the rates of medication reconciliation documentation results in safer and higher quality care. As providers, one must continually be aware of the concept of “self-prescribing” with OTC medications that fall into a high-risk category. The Beers list is one of many tools available to minimize the prescribing of inappropriate
M. V. Vejar et al.
medications for the elderly. Some of the medications listed on the Beers list do not require prescriptions, and thus it is important to encourage patients to brown-bag their medications for review by providers and/or pharmacists. Clinicians should look beyond what the “active” medication list may say and consider the possibility of inaccuracies. Medication management plays a pivotal role in reducing both the use of high-risk medications and duplicate medication therapy. In any clinical practice setting, the role of QI should be actively implemented, allowing for continual evaluation of practice and processes for care allowing for effective changes to be made accordingly. The role of an advanced practice nurse practitioner (APNP) should incorporate evidence-based practices that focus on improving quality in the healthcare system. QI is a method APNPs may use to assist in contributing to safer and higher quality patient care.
References American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012). American geriatrics society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(3), 1–16. doi:10.1111/j.1532-5415.2012.03923.x Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K. L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: A systematic review. Research in Social and Administrative Pharmacy, 8, 60–75. doi: 10.1016/j.sapharm.2010.12.002 Cumbler, E., Wald, H., & Kutner, J. (2010). Lack of patient knowledge regarding hospital medications. Journal of Hospital Medicine, 5, 83–86. doi:10.1002/jhm.566 ¨ S.-L., Lyles, A., & Leikola, S. N. Dimitrow, M. S., Airaksinen, M. S. A., Kivela, S. (2011). Comparison of prescribing criteria to evaluate the
Medication management for older adults
appropriateness of drug treatment in individuals aged 65 and older: A systematic review. Journal of the American Geriatrics Society, 59, 1521–1530. doi:10.111/j.1532-5415.2011.03497.x Gray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care Pharmacy, 15, 568–571. Guaraldo, L., Cano, F. G., Damasceno, G. S., & Rozenfeld, S. (2011). Inappropriate medication use among the elderly: A systematic review of administrative databases. BMC Geriatrics, 11(1), 79. doi:10.1186/1471-231811-79 Institute for Healthcare Improvement. (2011). How-to guide: Prevent adverse drug events by implementing medication reconciliation. Cambridge, MA: Institute for Healthcare Improvement. Institute of Medicine. (2006). Preventing medication errors. Retrieved from http://www.iom.edu/˜/media/Files/Report%20Files/2006/PreventingMedication-Errors-Quality-Chasm- Series/medicationerrorsnew. ashx Jano, E., & Aparasu, R. R. (2007). Healthcare outcomes associated with Beers’ Criteria: A systematic review. Annals of Pharmacotherapy, 41, 438– 448. Joint Commission. (2011). National patient safety goals effective July 1, 2011: Ambulatory health care accreditation program. Retrieved from http://www. jointcommission.org/ assets/1/6/NPSG˙EPs˙Scoring˙AHC˙20110707.pdf Kaur, S., Mitchell, G., Vitetta, L., & Roberts, M. S. (2009). Interventions that can reduce inappropriate prescribing in the elderly: A systematic review. Drugs Aging, 26, 1013–1028. Lewin, K. (1951). Field theory in social science: Selected theoretical papers (Harper Torchbook edition, 1964). New York: Harper and Row. Lowry, R. (2012). VassarStats: Website for statistical computation. Retrieved from http://faculty.vassar.edu/lowry/VassarStats.html Marcum, Z. A., Handler, S. M., Boyce, R., Gellad, W., & Hanlon, J. T. (2010). Medication misadventures in the elderly: A year in review. American Journal of Geriatric Pharmacotherapy, 8(1), 77–83. doi:10.1016/j.amjopharm. 2010.02.002 Peron, E. P., Gray, S. L., & Hanlon, J. T. (2011). Medication use and functional decline in older adults: A narrative review. American Journal of Geriatric Pharmacotherapy, 9(6), 378–391. doi:10.1016/j.amjopharm.2011.10.002 Shepherd, G., Mohorn, P., Yacoub, K., & May, D. W. (2012). Adverse drug reaction deaths reported in United States vital statistics, 1999–2006. Annals of Pharmacotherapy, 46, 169–175. doi:10.1345/aph.1P592
7
Medication management for elderly patients in an academic primary care setting: A quality improvement project Maria V. Vejar, RN, DNP, GNP-BC (Nurse Practitioner)1 , Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, FAAN (Associate Professor)2 , & Ernestine Kotthoff-Burrell, PhD, APRN, FAANP (Assistant Professor)2 1 2
Division of Geriatrics, School of Medicine, University of Colorado, Aurora, Colorado College of Nursing, University of Colorado, Aurora, Colorado
Keywords Adverse drug events; allergy; geriatric; medications; safety. Correspondence Maria V. Vejar, RN, DNP, GNP-BC, Division of Geriatrics, School of Medicine, University of Colorado, 1635 Aurora Court, 5th Floor, Seniors Clinic, University of Colorado Hospital, Aurora, CO 80045. Tel: 720-848-3416; fax: 720-848-3401 Received: February 2013; accepted: May 2013 doi: 10.1002/2327-6924.12121
Abstract Purpose: Medication reconciliation is a National Patient Safety Goal. Completing medication reconciliation minimizes the risk for preventable adverse drug events (ADEs). The elderly are at greatest risk for ADEs because of their high number of comorbidities and medications usage. The purpose of this quality improvement project was to improve medication management in a geriatric primary care practice. Interventions focused on improving medication reconciliation documentation, improving accuracy of medication lists, reducing inappropriate medication use, and minimizing duplicate medication therapy. Data sources: A pre/post design was used over a 9-month period. Interventions focused on educating providers, staff, and patients on medication management. Analysis of 1580 manual chart audits and 903 patient questionnaires were completed. Conclusions: Outcomes improved in all four performance outcomes: medication reconciliation—χ 2 (1, N = 576) = 32.00, p < .0001, V = 0.4; patients bringing medications to clinic—χ 2 (1, N = 277) = 90.46, p < .0001, V = 0.7; reduction in use of specific medications—χ 2 (1, N = 267) = 19.49, p < .0001, V = 0.3; and duplicate therapy was reduced—χ 2 (1, N = 267) = 45.13, p < .0001, V = 0.5. Implications for practice: Improved medication management had a significant impact in patient safety and quality of care in this clinic.
Background knowledge Medication management and safety is a nationally recognized health issue. The Joint Commission (JC) has chosen medication management and reconciliation as one of its primary National Patient Safety Goals (Joint Commission [JC], 2011). Medication management is the process of educating both patient and provider on the safe usage of prescription and over-the-counter (OTC) medications. This process includes medication reconciliation, which involves compiling and using an accurate list of all medications the patient is taking (Institute for Healthcare Improvement [IHI], 2011). In addition to a fully reconciled list of medications, another goal is for the patient to understand why each medication is being taken, and the potential adverse reactions he or she may experience with the specific medication(s). C 2014 American Association of Nurse Practitioners
Although medication reconciliation is a requirement by JC, there are challenges in successfully implementing the process (IHI, 2011). Some difficulties in completing medication reconciliation include the following: lack of a standardized process, time restraints, patients not fully aware of all the medications they take, inaccuracies in the medication list, and often a focus on documentation rather than completing the process (IHI, 2011). The cost of not completing medication management is significant. Results from a recent study estimated 8000– 12000 deaths per year related to adverse drug events (ADEs; Shepherd, Mohorn, Yacoub, & May, 2012). Individuals aged 75 and older were found to be at higher risk for ADEs (Shepherd et al., 2012). Another study found many discrepancies between the actual medications the patient was using versus the medications the provider recorded as being taken. (Cumbler, Wald, & Kutner, 2010). 1
Medication management for older adults
In particular, ADEs are a significant concern in the elderly population because of their high number of comorbidities and medications usage (Gray & Gardner, 2009). It is estimated that treatment for medication errors and ADEs is in excess of $880 million per year for older adults (Institute of Medicine, 2006). The Beers criteria is a resource to assist providers in identifying and avoiding potentially dangerous prescription and OTC medications used by seniors (American Geriatrics Society 2012 Beers Criteria Update Expert Panel [AGS], 2012). These inappropriate drugs place the older adult at greater risk for ADEs (AGS, 2012).
M. V. Vejar et al.
and naproxen; (d) if it was determined that a problem with duplicate drug therapy existed, a reduction in the use of the duplicate medications and potential drug–drug interactions was desired. This QIP was patient-centered, with a focus on quality and safety issues. It was designed to be a collaborative effort to include all members of the senior’s clinic team. The quality improvement (QI) team consisted of care team assistants, medical assistants (MAs), registered nurses, a social worker, pharmacists, clinic providers (physicians, a nurse practitioner, and a physician assistant), and administrators. A geriatric nurse practitioner was identified as the team leader for the project.
Local problem A systems assessment of a ”senior’s clinic,” the practice site for this project, revealed that medication reconciliation was far below the JC national standard of 90% (JC, 2011). The clinic medication reconciliation rate was 53% in March 2011 (D. Franco, personal communication, March 3, 2011). Because the failure to conduct regular medication reconciliation is a serious issue that may result in potentially life-threatening consequences, a quality improvement project (QIP) was launched to address the gap in practice.
Intended improvement The QIP began with the intention of raising the rate of medication reconciliation to the national standard of 90% or higher over 1 year. Efforts were made to establish new behaviors where patients would bring all their medications to each clinic visit, including OTC medications. As the QIP progressed, the focus expanded into a broader sense of medication management, which included reducing the use of specific OTC medications and duplication of medications. The primary aim of this QIP was to decrease the risk for potentially preventable ADEs caused by drug–drug interactions, medication duplication, and the use of potentially inappropriate medications for the elderly through improved medication management and medication reconciliation. Four specific aims were defined to measure the success of this QIP: (a) Improve the rate of medication reconciliation from 53% to 70% within 6 months and reach a target of 90% within 12 months; (b) implement a process for patients to bring all their medications (including OTCs) to their scheduled clinic visits, starting with a benchmark of 0% to a goal of 75% within 12 months; (c) reduce the use of four potentially dangerous OTC medications, specifically diphenhydramine, Tylenol PM (which contains diphenhydramine), and nonsteroidal anti-inflammatory drugs (NSAIDs), specifically ibuprofen 2
Methods Ethical issues This QIP followed principles of QI and did not require Institutional Review Board approval. An external review of the project proposal was completed by the University of Colorado’s College of Nursing Doctorate of Nursing Practice COMIRB approval committee to ensure the project aims and intended interventions were consistent with QI. Minimal risk to patients was involved, as the process for medication management was part of an established standard of care. Confidentiality was maintained by de-identifying data and maintaining the data in a password-protected computer; questionnaires were kept in a locked cabinet.
Setting The senior’s clinic is a primary care practice located within a large academic setting in the mountain region of the United States. The average age of the patient population is 81 years, with a range of 51 years to 102 years. The senior’s clinic main focus is providing high-quality, comprehensive, evidenced-based care to patients while teaching students in the various academic programs on campus. At the foundation of this QIP was the concept of change. Lewin’s ”change theory” provided the theoretical framework to guide this project (Lewin, 1951). Lewin advised change should not be focused on reaching a specific goal but rather transitioning from the present level to the desired level. The concept of group dynamics was specifically addressed by Lewin, and this related directly to this QIP, given that the senior’s clinic is an interprofessional practice consisting of one geriatric nurse practitioner, seven physicians, one physician assistant, and three MAs.
M. V. Vejar et al.
Planning the interventions and study of the interventions Baseline performance data were obtained from the clinical information technology department providing the clinic’s current compliance with medication reconciliation. A root cause analysis was completed to identify potential causes for the low compliance rates. The two primary findings were that providers forget to document medication reconciliation in the appropriate location and patients were not fully aware of what their active medications were. Initial interventions were developed based on these findings. This QIP utilized a pre- and postintervention design. The preintervention time frame was from October 2010 to May 2011 and postintervention data assessment took place in June 2011–January 2012. Multiple interventions based on the literature, team feedback, and monthly reviews of outcome progress were implemented throughout the QIP. Open communication took place in both group and individual meetings with QI team members. Several Plan–Do–Study–Act (PDSA) cycles were completed for each specific aim in this QIP. Several interventions were implemented to improve outcomes 1–4; overall first to last observations for each outcome variable were measured. Benchmark data, 1 month of preintervention observations, were compared to the last month of observations, at the conclusion of this 1-year project. Individual impact of process improvement interventions were not measured as the QIP focused on processes to improve clinical practice outcome (e.g., outcome measures 1–4) The first goal of the project was to improve medication reconciliation documentation. Ten discrete and overlapping interventions were implemented over 11 months (see Table 1). Specific providers were identified as having difficulties with the electronic medical record (EMR) medication reconciliation process. Directed training efforts were provided for these providers in addition to the group as a whole. For each provider, data were collected through monthly EMR audits of clinic patients. Progress of this outcome was discussed in monthly team meetings. Interventions to achieve the second project aim focused on obtaining a comprehensive picture of all the medications that patients were taking to maintain an accurate active medication list in the EMR. An essential step of medication reconciliation is verification that providers are aware of all medications patients take, including OTC medications and natural supplements. Because bringing medications to the clinic was an important part of medication management, the planned interventions focused on educating clinic patients and QI team members about
Medication management for older adults
Table 1 Interventions for outcome 1: Improving medication reconciliation documentation Interventions implemented to improve practice with medication reconciliation documentation • Phone calls to patients reminding them to bring their medications to the clinic visit. • Placement of educational flyers for patients in exam rooms discussing medication management. • Patient questionnaires completed at check-in and check-out of clinic visit by care team assistants. • Provider education one-on-one and e-mails. • Provider reminder notes for documenting medication reconciliation placed in each exam room. • Educated new providers in clinic on medication reconciliation documentation. • Provider education given at faculty division meeting. • Intensification of provider education after transitioning to new EMR system. • Provider education both as a group and one-on-one at Division meeting and in clinic. • Automated reminder in EMR started in mid-October 2011. Table 2 Interventions for outcome 2: Increasing number of patients that brown-bag Interventions implemented to have patients “brown-bag” medication for clinic visit • Reminder phone calls to patients to bring medications to the clinic visits. • Patient questionnaires completed at the time of each visit, tracking if patients brought their medications to the visit and if the provider discussed the medications. • Flyers placed throughout clinic educating patients and team on “brown-bagging” medications. • Educated team members to remind patients of “brown-bagging” • Reminder phone message asking patients to bring all their medications to their clinic visit. • Follow-up patient questionnaires to assess how well the interventions were working. • Focused on improving support from MAs in patient education and data collection.
this process. The concept of “brown bagging” was introduced into the clinic practice. The process of brown bagging involves patients using a bag as a method of transporting all of their medications from home to the clinic. Table 2 outlines the series of interventions implemented to increase a comprehensive review of patient medications at each clinic visit. Data collection was completed through the use of a patient questionnaire that tracked if patients brought their medications to the visit. In total, 903 patient questionnaires were completed. Findings from earlier PDSA cycles revealed that when patients physically brought their OTC medications to the visit, many were using high-risk medications without the provider’s knowledge or consent. 3
Medication management for older adults
Table 3 Interventions for outcome 3: Reducing use of high-risk OTC medications Interventions implemented to reduce the use of OTC high-risk medications • Flyer placed in exam rooms with emphasis on high-risk medications and ADEs. • Educated patients to bring all medications, including OTC medications, to each visit. • Initiated a more detailed patient questionnaire to be used for data collection and followup. • Educated patients that OTC medications should not be considered safe. • Directed toward MAs involvement with patient education and data collection.
Table 4 Interventions for outcome 4: Reducing duplicate medication therapy Interventions implemented to reduce the use of duplicate medications • Provider e-mails to obtain recall information on patient duplicate therapy use. •· Pharmacist e-mails to obtain recall information on patient duplicate therapy use. • Patient questionnaires to collect data for duplicate therapy use. • Patient education on “brown bagging" continued. • Provider follow up regarding duplicate therapy.
The third specific aim of the study was to reduce the use of four potentially dangerous OTC medications, specifically diphenhydramine, Tylenol PM, and the NSAIDs naproxen and ibuprofen. It was unclear at the start of this QIP if this process outcome would be a significant issue in the practice. Interventions focused on identifying if clinic patients were taking specific OTC medications that were classified as being potentially dangerous based on the Beers criteria (AGS, 2012). Because OTC medications can be unsafe for patients if taken alone or with their other routine medications, PDSA cycles were planned to educate patients and family members of this danger. Table 3 provides a summary of the interventions to meet this study aim. The use of OTC medications was obtained by the patient’s self-report on the questionnaire. Based on patient questionnaire responses, providers educated patients on safe medication use (see Table 4). The last project aim explored duplication in medication therapy in the senior’s clinic population. Data were collected in two ways. First, provider recall was used to identify if providers felt duplication was an issue. Second, PDSA cycles tracked medication duplication based on patient questionnaires, review of medications brought to the visits, and EMR medication list evaluation. Figure 1 is a run chart demonstrating overall practice improvement for QIP outcome measures 1–4. 4
M. V. Vejar et al.
Results Each of the four outcomes utilized a pre- and postgroup analysis. EXCEL was used for data collection. SPSS version 19 and VassarStats (Lowry, 2012) were used for data analysis. VassarStats was used, since this statistical program weighs pre/post frequency data by sample size, to determine expected cell frequency. This program also allowed comparison of pre/post aggregate data using cell totals rather than individual lines of data. Descriptive statistics and chi-square analysis were completed on all four project outcomes. Cramer’s V was used to interpret the effect size from the results of the chi-square analysis. A quantitative data analysis for outcome 1 was completed with data from 1580 manual EMR chart audits. Outcomes 2–4 were analyzed using both predata and data from 903 completed patient questionnaires with matching chart audits.
Outcome 1 At baseline, the benchmark rate for successfully documenting medication reconciliation was 64% in the senior’s clinic. Chi-square analysis compared the preintervention compliance (64%) to postintervention compliance (96%) of medication reconciliation. Of these 576 data points, 360 chart reviews were in the preobservation period and 216 were in the postobservation period. The overall improvement in provider documentation of medication reconciliation for each clinic visit was found to be statistically significant (χ 2 [1, N = 576] = 32.00, p < .0001, V = 0.4). The Cramer’s V of 0.40 suggests a moderate strength of association between the interventions and outcome of medication reconciliation.
Outcome 2 Baseline data for the percentage of patients who brought all their medications, including OTC medications, to each clinic visit were 0%. Post intervention, 64% of patients brought all their medications to clinic visits. Of the 277 data points, 61 were in the preintervention phase of the QIP and 216 comprised the postintervention observation data. Data analysis revealed a statistically significant improvement in the number of patients who did participate in brown bagging for their clinic visits (χ 2 [1, N = 277] = 90.46, p < .0001, V = 0.67). For this outcome, Cramer’s V of 0.67 suggests a moderately strong association between the interventions and outcome of medications brought to each clinic visit. Descriptive statistics from the 903 patient questionnaires revealed the mean age 79.5 (SD ± 6.9) with 68.7% being women and 31.3% were men.
Medication management for older adults
M. V. Vejar et al.
120 100 80
% Medication Reconciliation
60
% Patients Bringing Medications
40
% OTC Usage
20
% Duplicate Therapy
0
Figure 1 Visual representation of the overall changes in outcomes 1–4 run chart.
Outcome 3 At baseline, 46% of patients reported using one or more high-risk and potentially dangerous OTC medications being tracked. Chi-square analysis compared the preintervention usage (46%) to postintervention usage (17%) of these higher risk medications. A total 216 charts were reviewed, in which 51 were in the preintervention data and 216 were in the postintervention data. Analysis of data revealed a statistically significant reduction in the use of these high-risk medications (χ 2 [1, N = 267] = 19.49, p < .0001, V = 0.31). Cramer’s V of 0.31 suggested a weak association between interventions and outcome of reducing the use of these potentially dangerous OTC medications. Descriptive analysis demonstrated the most commonly used OTC medications were NSAIDs accounting for 14.5% followed by diphenhydramine at 5%. Nearly 50% of the OTC NSAIDs being used by patients were not reflected in their active medication list, and 0% of diphenhydramine use was noted in the medication list.
Outcome 4 Benchmark data for provider recall regarding duplication therapy in clinic revealed 80% of providers and pharmacists felt duplication was a problem less than 25% of the time and 20% felt it was between 25% and 50%. For this analysis, there were 267 charts in which the preintervention group consisted of 51 chart audits and 216 postintervention chart audits. Baseline data revealed patients were actually using duplicate medication therapy 39% of the time and post data found duplication of
medication to be 1%, a 38% reduction. Medications more commonly found to be duplicated between OTC and prescribed medications were NSAIDs and sedatives. Chisquare analysis showed a statistically significant decrease in duplicate medication therapy (χ 2 [1, N = 267] = 45.13, p < .0001, V = 0.47). The Cramer’s V of 0.47 suggested a moderately strong association between the QIP interventions and the reduction in duplicate medication usage.
Discussion Education played a significant role in increasing medication reconciliation rates and patients brown-bagging medications. In addition, there was a notable decrease in patient use of high-risk OTC medications. Accuracy of medication lists improved throughout this QIP, and resulted in a decrease of duplicate medication therapy. See Figure 1 for a collective graphic representation of the results these outcomes. The most effective interventions found to improve the outcomes of medication reconciliation were reminder notes posted in each exam room and monthly discussions with the providers regarding the current compliance rates. The greatest challenge occurred at the time of transition to a new EMR, when medication reconciliation rates dropped to below 50%. Following this setback, individualized education was focused on the method of documenting medication reconciliation, resulting in increased compliance. The outcome goal of 75% was not met for patients brown-bagging medications. In retrospect, a goal of 75% 5
Medication management for older adults
was likely not reasonable, because patients did not regularly bring medications to their visits before the start of this QIP. The most effective intervention for increased brown bagging was the automated phone reminder system, which was adjusted to specifically ask patients to bring their medications to their clinic visits the following day. Brown bagging was an effective tool in improving accuracy of medication lists. The least effective intervention was the attempt to increase MA involvement with patient education. The MAs reported that this additional workload was difficult to add to existing responsibilities because of time restraints. This QIP identified an issue with the use of medications on the Beers list unknown to clinic providers. The most successful interventions included flyers posted throughout the clinic, and provider discussions following the completed patient questionnaires. The greatest challenges with interventions were attempts made to gain further participation with the clinic MAs with both patient education and data collection. This QIP identified a problem with duplicate therapy, primarily with specific OTC medications listed on the Beers list. Consistent with the previous two outcomes, interventions directed toward increasing MA participation were met with the greatest resistance to change from the status quo. The most successful interventions were those involving patient education on the dangers of duplicate therapy and the need for an accurate active medication list, which included OTC medications.
Relation to other evidence The topic of medication management is well documented in current literature. The results of this QIP are consistent with findings from several systematic reviews ¨ (Chhabra et al., 2012; Dimitrow, Airaksinen, Kivela, Lyles, & Leikola, 2011; Guaraldo, Cano, Damasceno, & Rozenfeld, 2011; Jano & Aparasm, 2007; Kaur, Mitchell, Vitetta, & Roberts, 2009; Marcum, Handler, Boyce, Gellad, & Hanlon, 2010; Peron, Gray, & Hanlon, 2011). Upon conclusion of this QIP, the clinic was in compliance with the JC National Patient Safety Goals on medication reconciliation, which is associated with improved patient care and outcomes (Chhabra et al., 2012; Guaraldo et al., 2011; Kaur et al., 2009). Improvements in medication management throughout this project increased accuracy of existing patient medication lists and potentially assisted with reducing preventable ADEs, consistent with existing literature (Chhabra et al., 2012; Guaraldo et al., 2011; Jano & Aparasm, 2007; Kaur et al., 2009; Marcum et al., 2010). The collaborative team approach used throughout this process was effective in improving medication management. These findings were similar to 6
M. V. Vejar et al.
those of Chhabra et al. (2012) and Kaur et al. (2009). Both senior’s clinic providers and pharmacists played instrumental roles in medication management, as reported in other studies (Chhabra et al., 2012; Dimitrow et al., 2011; Kaur et al., 2009). Tools, such as the Beers criteria, used to guide providers in minimizing the use of inappropriate medications for the older adults are supported in the literature (Guaraldo et al., 2011; Peron et al., 2011) and were found valuable in this QIP. Inappropriate prescribing for the elderly places these patients at greater risk for ADEs (Dimitrow et al., 2011; Guaraldo et al., 2011; Jano & Aparasur, 2007; Kaur et al., 2009; Marcum et al., 2010; Peron et al., 2011). A topic for future study is the consideration of OTC medications on the Beers list being self-prescribed by patients without the knowledge or approval of their providers (Chhabra et al., 2012).
Limitations One of the limitations was limited benchmark data, specifically for outcomes 2–4. Despite the number of interventions completed throughout this QIP, the actual effect of each intervention cannot be fully determined. Interventions for this QIP were based on the process and team dynamics of this senior’s clinic; thus the findings from the project may not be generalizable to other geriatric clinical practice settings.
Strengths Strengths of this QIP included an increased awareness among providers of the importance of improved medication management in this practice setting. Patients and providers both benefited from education regarding Beers criteria in reducing the use of some high-risk medications. Improved medication management enabled the senior’s clinic to reach the nation standards for medication reconciliation.
Conclusions The key findings of this QIP may be used to improve medication management in other settings. Clinicians should remember the importance of using a collaborative team approach with the patient being at the center. A team approach was effective in improving patient care and medication management in this practice setting. Improving the rates of medication reconciliation documentation results in safer and higher quality care. As providers, one must continually be aware of the concept of “self-prescribing” with OTC medications that fall into a high-risk category. The Beers list is one of many tools available to minimize the prescribing of inappropriate
M. V. Vejar et al.
medications for the elderly. Some of the medications listed on the Beers list do not require prescriptions, and thus it is important to encourage patients to brown-bag their medications for review by providers and/or pharmacists. Clinicians should look beyond what the “active” medication list may say and consider the possibility of inaccuracies. Medication management plays a pivotal role in reducing both the use of high-risk medications and duplicate medication therapy. In any clinical practice setting, the role of QI should be actively implemented, allowing for continual evaluation of practice and processes for care allowing for effective changes to be made accordingly. The role of an advanced practice nurse practitioner (APNP) should incorporate evidence-based practices that focus on improving quality in the healthcare system. QI is a method APNPs may use to assist in contributing to safer and higher quality patient care.
References American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012). American geriatrics society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(3), 1–16. doi:10.1111/j.1532-5415.2012.03923.x Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K. L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: A systematic review. Research in Social and Administrative Pharmacy, 8, 60–75. doi: 10.1016/j.sapharm.2010.12.002 Cumbler, E., Wald, H., & Kutner, J. (2010). Lack of patient knowledge regarding hospital medications. Journal of Hospital Medicine, 5, 83–86. doi:10.1002/jhm.566 ¨ S.-L., Lyles, A., & Leikola, S. N. Dimitrow, M. S., Airaksinen, M. S. A., Kivela, S. (2011). Comparison of prescribing criteria to evaluate the
Medication management for older adults
appropriateness of drug treatment in individuals aged 65 and older: A systematic review. Journal of the American Geriatrics Society, 59, 1521–1530. doi:10.111/j.1532-5415.2011.03497.x Gray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care Pharmacy, 15, 568–571. Guaraldo, L., Cano, F. G., Damasceno, G. S., & Rozenfeld, S. (2011). Inappropriate medication use among the elderly: A systematic review of administrative databases. BMC Geriatrics, 11(1), 79. doi:10.1186/1471-231811-79 Institute for Healthcare Improvement. (2011). How-to guide: Prevent adverse drug events by implementing medication reconciliation. Cambridge, MA: Institute for Healthcare Improvement. Institute of Medicine. (2006). Preventing medication errors. Retrieved from http://www.iom.edu/˜/media/Files/Report%20Files/2006/PreventingMedication-Errors-Quality-Chasm- Series/medicationerrorsnew. ashx Jano, E., & Aparasu, R. R. (2007). Healthcare outcomes associated with Beers’ Criteria: A systematic review. Annals of Pharmacotherapy, 41, 438– 448. Joint Commission. (2011). National patient safety goals effective July 1, 2011: Ambulatory health care accreditation program. Retrieved from http://www. jointcommission.org/ assets/1/6/NPSG˙EPs˙Scoring˙AHC˙20110707.pdf Kaur, S., Mitchell, G., Vitetta, L., & Roberts, M. S. (2009). Interventions that can reduce inappropriate prescribing in the elderly: A systematic review. Drugs Aging, 26, 1013–1028. Lewin, K. (1951). Field theory in social science: Selected theoretical papers (Harper Torchbook edition, 1964). New York: Harper and Row. Lowry, R. (2012). VassarStats: Website for statistical computation. Retrieved from http://faculty.vassar.edu/lowry/VassarStats.html Marcum, Z. A., Handler, S. M., Boyce, R., Gellad, W., & Hanlon, J. T. (2010). Medication misadventures in the elderly: A year in review. American Journal of Geriatric Pharmacotherapy, 8(1), 77–83. doi:10.1016/j.amjopharm. 2010.02.002 Peron, E. P., Gray, S. L., & Hanlon, J. T. (2011). Medication use and functional decline in older adults: A narrative review. American Journal of Geriatric Pharmacotherapy, 9(6), 378–391. doi:10.1016/j.amjopharm.2011.10.002 Shepherd, G., Mohorn, P., Yacoub, K., & May, D. W. (2012). Adverse drug reaction deaths reported in United States vital statistics, 1999–2006. Annals of Pharmacotherapy, 46, 169–175. doi:10.1345/aph.1P592
7
![[Primary care for diabetic patients: a quality improvement cycle].](/assets/img/hold.png)
