Is Your Facility Preventing ADE’s?

by Timothy Gieseke, MD, CMD

In the 2014 OIG Study on the quality of SNF care, the authors concluded that 59% of the adverse events were clearly or likely preventable and 66% of these events were related to medications.   In other studies, 5-28% of acute hospitalizations in geriatric populations are due to ADE's (Adverse Drug Events).  In nursing homes, for each $1.00 spent on medications, $1.33 is spent as a consequence of an ADE.

Appropriate prescribing is actually quite difficult and complex.  Not only do we need to select the right drug for the right patient, but also need to consider drug-drug and drug-disease interactions as well as the cumulative effect of common drug side effects like anticholinergic side effects, QT interval prolongation, and drugs which increase serotonin levels.  Certain classes of drugs are more risky like Cardiovascular drugs, Diuretics, NSAIDS, Hypoglycemics, and Anticoagulants.  People taking 7 or more drugs have an 82% chance of an ADE.

We need to become experts on drug side effects because most of us see better once we are taught about what to look for.  This needs to become a part of nursing school curriculum.  As a former Chair of Pharmacy and Therapeutics committee at a local HMO and Hospital, I have valued the information received on new drugs.  I’ve also found apps for phones, tablets, and computers like Epocrates, IGeriatrics (Beer’s List), and Medscape to be quite helpful for identifying the above pharmacologic issues.  Despite this, I occasionally error by relying on my memory and prior experience rather than using tools like Epocrates “Interaction Check” tool.

As you read the following real case, ask whether your facility could have prevented this ADE.  I have a long stay patient in her 70’s of normal weight that developed acute mania with vague history of prior mental illness poorly defined.  With the help of a clinical psychologist (prior psychiatric history details clarified) and 1 visit from a geropsychiatrist consultant, we successfully managed this flare with Geodan and then slowly added Venlefaxine for her pre-morbid lifelong depression.  After she returned to baseline status in about a month, Geodan was tapered slowly from 60 mg q 12 hr down to 40 mg q 12 hr down to 20 mg q 12 hr.  At this time desiring to DC Geodan in the near future, I decided to add Lithium 300 mg bid as a safer maintenance medication.  On the 4th day, the patient at change of shift was noted to be diaphoretic, confused, unable to speak, thrashing in bed, and tachycardic.  She was transferred to the ER where a drug was stopped, she quickly improved, and was able to return to the facility.  The next day she was back to baseline status.

This patient had serotonin syndrome which was first identified in 1987 in the famous case of Libby Zion, which resulted in the Libby Zion Law.  I’ve attached a link to a nice Wikipedia review on this subject and case. (https://en.wikipedia.org/wiki/Serotonin_syndrome ).  This is actually quite common, but usually not recognized.  In severe cases it can result in death, as it did for Libby Zion.  For myself, I will use Epocrates app on drug interactions prior to prescribing infrequently prescribed drug combinations. 

The drug that was stopped was Lithium.  Both Geodan and Venlefaxine raise serotonin levels as does Lithium.  Lithium was the final straw in this patient.  I believe in transparency, so I educated the staff on what had occurred, asked the DON to have the pharmacy investigate their lack of alarm for this potential ADE, and I personally contacted the family to let them know in detail what had happened and what we will be doing differently.

This is a challenging area of medicine.  On October 29, CALTCM is sponsoring a CME meeting at UCD which will include a presentation on polypharmacy and de-prescribing.

How is your facility working to minimize ADE's?  At CALTCM, we look forward to hearing your success stories in future issues of the WAVE.  

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