Originally published December 2013
Physicians play a key role in the effective management of medication, particularly as medical conditions and medication regimens become more complex. A sound understanding of medication management and careful attention to associated risk management strategies will help physicians provide quality care for their patients.
A review of CMPA legal cases that closed over a 7-year period between 2006 and 2012, indicates that the most prevalent medication-related issues, in order of frequency, were related to:
a delay or failure to prescribe or administer a medication
the action or inaction of another healthcare provider
monitoring and follow-up issues related to medication
deficient history taking or evaluation relevant to medication
an injury during administration or preparation of medication
the wrong dosage being prescribed or administered
A number of different factors contributed to these medication issues. There was also a range of clinical outcomes associated with these cases.
Of all CMPA legal cases that closed over this 7-year period, 10% had a medication issue.
Foundations for effective medication management
Medication management actually begins with the physician's assessment or evaluation of a patient to determine the need for medication. This is followed by selecting, ordering or prescribing, preparing, and administering drugs, and monitoring patients.
Depending on their medical practice, physicians will have more or less involvement with different aspects of this process. This is also the case for other healthcare professionals who have authority to prescribe medications. At all times doctors need a good understanding of their patients' health needs and the medications they prescribe. Physicians must also monitor patients taking medications.
Physicians will want to be familiar with and follow applicable medication management guidelines from their medical regulatory authority (College). In addition to policy statements on topics such as prescribing, including self-prescribing, many Colleges have guidelines on related topics such as vaccine storage and handling, and the safe disposal of medications.
Clear communication about medications with patients or designated family members and healthcare providers across the continuum of care is important. This involves sharing information with pharmacists, nurses, midwives, and with other healthcare professionals at different levels and transitions of care. Comprehensive and timely documentation regarding medications in the patient's health record should never be overlooked.
Today, medication safety is largely based on a culture of safety and interdisciplinary collaboration.1 Given that doctors increasingly work in collaborative teams, it is important to clarify the roles and responsibilities of all healthcare professionals, and of patients, at all stages of the medication management process. Roles and responsibilities will vary depending on legislation, scopes of practice, regulations, organizational policies and procedures, and other factors. Doctors should be aware of their roles and responsibilities in the context of their medical practice.
Medication management for seniors
The number of seniors in canada increases annually. Most doctors will care for more patients over the age of 65 as demographics continue to shift. "in 2009, almost two out of three (63%) canadians age 65 and older took 5 or more prescription drugs from different drug classes, with close to one-quarter (23%) taking 10 or more.... Seniors also take more over-the-counter medications and vitamins or other supplements than any other age group, possibly adding to the risks associated with multiple medications".2 Medication reconciliation includes information on over-the-counter products.
Doctors treating seniors taking medications should be particularly attuned to the possibility of drug interactions. Drug knowledge, ongoing patient monitoring, as well as regular communication with pharmacists and other treating physicians can help reduce these risks.
Communicating effectively about medications is a critical component of delivering safe care. "using medication reconciliation, healthcare providers follow a formal process to work together with patients, families, and other healthcare professionals to ensure accurate and comprehensive medication information is communicated across transitions of care."3
Whether working in hospitals, long-term care facilities, clinics, or other settings, doctors have an important role to play in helping to collect the best possible medication history, comparing what the patient is actually taking with what is prescribed, and communicating and resolving medication discrepancies. Physicians' specific roles in medication reconciliation may vary depending on their responsibility within the healthcare team. Clear assignment of roles and responsibilities, within a context of shared accountability is required. Since the process can involve multiple healthcare professionals, effective communication is essential. Doctors should also emphasize the patient's role in this process and use the institution or community pharmacist's expertise as required.
Medication reconciliation is not just for doctors working in institutions. Family doctors have an ongoing relationship with their patients and are often the custodian of the medication list. In this way, medication reconciliation may be viewed as an ongoing process (e.g. whenever the patient visits, when the pharmacy calls, when incoming records from other specialists are received) involving family doctors and other key stakeholders within the patient's circle of care.4
The patient is in the best position to be aware of all the medications prescribed by multiple caregivers. Physicians should encourage patients, family, and caregivers to maintain an accurate list of all medications, and to review and update the list at each care encounter.5
Tips for safer prescribing
While physicians are not the only prescribers of medication, they do write the majority of prescriptions in canada. Prescribing medications is a complex process and physicians should use a systematic approach. The following tips may help physicians minimize the risks associated with prescribing.6
Remain up-to-date about medications, especially for the conditions commonly treated.
Have the appropriate information about the patient and the drug to help avoid prescribing errors. Accessing up-to-date medical records is critical.
Involve patients in prescribing decisions and when to return for monitoring or review. Include medication risks, side effects, and alternative choices in the consent discussion.
Be vigilant when writing paper or electronic prescriptions, and also double-check new prescriptions. This will help in making wise prescribing choices and mitigate the likelihood of errors before they reach the pharmacist or the patient. Consider if it is necessary to prescribe the drug at all.
Be aware of high-risk patients and high-risk drugs. High-risk patients include those with serious illnesses, those taking multiple medications, the very young, and the elderly.
Check computerized drug alerts regarding information about interactions or drug allergies.
Consider having high levels of safety built into any repeat prescribing system.
Have safe and effective ways of communicating medication information between primary and secondary care, and acting on medication changes suggested or initiated by other clinicians.
Be wary of abbreviations that could be misinterpreted and possibly lead to harmful medication errors. It is best not to use abbreviated drug names. Prescriptions should include directions such as "daily" or "every other day" instead of QD or QOD. Drug orders should not have a trailing zero (e.g. use 5 mg instead of 5.0 mg) and when decimals are used, they should never be left "naked" (e.g. 0.5 mg instead of .5 mg).
A review of medication errors and near miss incidents reported to the institute for Safe Medication Practices Canada (ISMP Canada) identified narcotic (opioid) drugs to be one of the more frequently reported causes of patient injury. Patient safety issues regarding narcotics can arise due to the large selection of narcotic products and available concentrations, the variety of dosage forms, look-alike and sound-alike names, packaging and labeling, infusion pumps and patient-controlled analgesia, and patient monitoring requirements.7
While narcotics are very important and necessary medications when used appropriately, physicians are urged to take the necessary precautions when managing these and other high alert medications.
The 10 rights of medication administration8
Physicians should verify the appropriateness of a number of factors when dealing with medications. These are: right patient, right medication, right dose, right time, right route, right form, right reason, right education (for patient), right response, and right documentation. Doctors alone are not necessarily responsible for all of these factors in all cases, however asking these questions will help to increase medication safety.
Technologies to enhance medication safety
The rapid advances in healthcare technology can assist physicians in managing medication, but may also introduce new challenges. New healthcare technologies include electronic health records, medical apps or support systems to assist patient diagnosis and treatment decisions, computerized physician order systems (ePrescribing), and computerized drug interaction alerts. Doctors should familiarize themselves and ask questions about new technologies, being vigilant about issues related to medication safety.
Disclosing and reporting medication issues
Doctors should disclose medication-related adverse events to patients and report these within their organizations through appropriate channels for the purpose of reducing such events in future. Physicians can also participate in ISMP Canada's Medication Incident and Near Miss Reporting Program, which is designed to collect, collate, and analyze actual and potential medication errors reported by healthcare practitioners. The intent of this voluntary program is to develop and disseminate recommendations and strategies to reduce medication errors. ISMP Canada encourages reporting so that health professionals across the country can learn from medication incidents. The information submitted is kept strictly confidential and protected, and there is an online reporting form.9
Physicians should also be familiar with the Canada Vigilance Program, which is the Health Canada post-market surveillance program that collects and assesses reports of suspected adverse reactions to both prescription and non-prescription medications. The Canada Vigilance Program provides a variety of tools for health professionals to report suspected adverse reactions. Reporting can be done online.
Resources for physicians
Depending on the nature of the concern, physicians with questions about prescribing drugs or managing medications can contact a pharmacist, their medical regulatory authority, or ISMP Canada. CMPA members with medico-legal questions associated with medication management should contact the Association to speak with a medical officer.
The CMPA has also published resources on risk management when using drugs or medical devices off-label, and risk management of medication issues in elderly patients.
Nicol, N., "Case study: An interdisciplinary approach to medication error reduction," American Journal of Health System Pharmacy (2007) Vol. 64, no. 14 p.17-20
Canadian Institute for Health Information, "Health Care in Canada, 2011: A Focus on Seniors and Aging," 2011. Retrieved on April 5 2013 from: http://www.cihi.ca/cihi-ext-portal/internet/en/document/health+system+performance/quality+of+care+and+outcomes/release_01dec11
Accreditation Canada, Canadian Institute for Health Information, Canadian Patient Safety Institute, ISMP Canada, "Medication reconciliation in Canada: Raising the bar," 2012. Retrieved on May 15 2013 from: http://www.accreditation.ca/uploadedFiles/Medication%20reconciliation%2010%2031%202012.pdf
Canadian Patient Safety Institute, "Safer Healthcare Now!" Webcast on Medication Reconciliation in Primary Care, February 12 2013. Retrieved on May 15 2013 from: http://www.saferhealthcarenow.ca/EN/Interventions/medrec/Pages/resources.aspx
College of Physicians and Surgeons of Ontario, "Assuring medication accuracy at transitions in care," 2008. Retrieved on April 8 2013 from: http://www.cpso.on.ca/members/resources/practicepartner/patientsafety/default.aspx?id=2804&terms=assuring+medication+accuracy
Medical Protection Society, "Tips for safe prescribing," Your Practice (2011) Vol. 5, no.4 p.9
Institute for Safe Medication Practices Canada, "Narcotic (Opioid) Medication Safety Initiative." Retrieved on June 14 2013 from: http://www.ismp-canada.org/NarcInit.htm
Parker, Cheryl, "For patient safety, obey the "10 rights" of medication administration," Canadian Healthcare Technology (November/December 2012) p.14
Institute for Safe Medication Practices Canada,
"Individual Practitioner Reporting, Medication Incidents Including Near Misses." Retrieved on November 15 2013 from: https://www.ismp-canada.org/err_ipr.htm