Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data

Poisoning in older adults: characterization of exposures reported to the Dutch Poisons Information Center

Introduction: The annual number of patients > 65 years old about whom the Dutch Poisons Information Center (DPIC) was consulted has more than doubled in the last decade. We aimed to gain insight in the type and circumstances of exposures reported to the DPIC involving older patients, in order to help prevent future poisonings. Methods: Enquiries to the DPIC involving patients > 65 years old were prospectively included from January 2019 to June 2019. Data were collected on patient characteristics (e.g., age, gender, and living situation) and exposure characteristics (e.g., type and exposure scenario). Results: In the first half of 2019, the DPIC was consulted about 1051 patients > 65 years old. The median age of the patients was 77 years old (range: 66-104 years) and women were over-represented (61%). A total of 1650 different substances were reported, 1213 pharmaceutical exposures (74%) and 437 non-pharmaceutical exposures (26%), mostly household products (n = 162). Most pharmaceutical exposures involved cardiovascular agents (n = 367, 30%), central and peripheral nervous system agents (n = 354, 29%), and analgesics (n = 152, 13%). In 71% of the patients exposed to pharmaceuticals, the drugs were taken unintentionally (n = 471), frequently caused by medication errors made by the patients themselves (n = 357, 76%). Most common scenarios included inadvertently taken/given a double (n = 140, 30%) or more than double (n = 94, 20%) dose or the wrong medication (n = 124, 26%). The most common scenario for unintentional exposure to non-pharmaceuticals was "mistook product for food/drink" (n = 122, 37%). Conclusions: The majority of intoxications in older adults are accidental and often involve medication errors. Unintentional poisoning is often preventable. If patients are cognitively impaired, potentially harmful substances should be kept out of their reach and medication should only be administered under direct supervision. Clear labelling, simplified drug regimens and the use of automatic medication dispensers could reduce the risk of medication errors in older patients.

Patterns of Medication Errors Involving Older Adults Reported to the French Medication Error Guichet

OBJECTIVES

The aims of the study were to describe medication errors (MEs) involving older adults reported to the French Medication Error Guichet and to compare them with MEs in younger adults, in each of the hospital and community settings.

METHODS

Retrospective secondary data analysis of MEs reported throughout 2013 to 2017 was performed. Descriptive and multivariate analyses were performed to compare actual and potential ME reports between older adults (aged ≥60 y) and younger adults (aged ≥18, <60 y).

RESULTS

We analyzed 4979 reports. In older adults, both in hospital (n = 1329) and community (n = 1264) settings, antithrombotic agents were frequently reported in MEs and were significantly more likely to be associated with reported MEs in older adults compared with younger adults. In hospital setting, antibacterials for systemic use (adjusted odds ratio [aOR] = 1.87, 95% confidence interval [CI] = 1.19-2.93) and antineoplastic agents (aOR = 2.22, 95% CI = 1.34-3.69), whereas in community setting, psycholeptics (aOR = 1.43, 95% CI = 1.04-1.98) and drugs used in diabetes (aOR = 6.01, 95% CI = 3.21-11.2) were more likely to be associated with reported MEs in older adults. In both settings, wrong dose and wrong drug were the most frequently reported error types in older adults; however, wrong technique error type (aOR = 2.06, 95% CI = 1.30-3.28) in hospital setting and wrong patient (aOR = 2.17, 95% CI = 1.30-3.60) in community setting were more likely to be associated with reported MEs in older adults.

CONCLUSIONS

We identified specific ME patterns for older adults, including antithrombotic agents in both settings; antibacterials for systemic use, antineoplastic agents, and wrong technique in hospital setting; and psycholeptics, drugs used in diabetes, and wrong patient in community setting. These findings inform future studies investigating population-specific medication safety strategies.

A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: A prospective cohort study

The Danish Poison Information Centre (DPIC) regularly receives inquiries about nursing home residents who have been exposed to a medication error. The aim of this prospective cohort study was to describe and discuss the types and consequences of these errors. Data were collected from 1 March 2018 to 31 March 2019. Registered data included characteristics of caller and resident, data related to the suspected medication error, risk assessment and recommendation. Consequences and clinical outcomes were assessed by follow-up telephone calls. Over the study period, the DPIC was consulted about 145 medication errors occurring at Danish nursing homes. The median number of substances administered by error was two (interquartile range 1-5). Hospitalization was recommended in 21% of cases. In one-third of the cases where consultation with the DPIC was done with the resident either on his/her way to or in hospital, hospitalization was found unnecessary, and the resident could have stayed in accustomed surroundings for observation. Follow-up demonstrated that very few medication errors had a severe outcome. This prospective study illustrates that consulting with a poison information centre can qualify risk assessment and potentially reduce hospital admissions following medication errors in a nursing home setting.

Increasing adverse drug reaction reporting-How can we do better?

Adverse drug reactions (ADRs) are associated with morbidity and mortality worldwide. Although national systems for reporting ADRs exist there is a low reporting rate. The aim of the current study was to evaluate an intervention plan for improving ADRs reporting among medical professionals (physicians and nurses). A multicentre intervention study was conducted, in which one medical centre was randomly assigned to the intervention group and two medical centres to the control group. The study consisted of 3 phases: baseline data collection, intervention and follow-up of the reporting rate. The questionnaire that was filled in at base line and at the end of study, contained questions about personal/professional demographic variables, and statements regarding knowledge of and behaviour toward ADRs reporting. The intervention program consisted of posters, lectures, distant electronic learning and reminders. An increase in the number of ADRs reports was noted in the intervention group (74 times higher than in the control group) during the intervention period, which was gradually decreased with as the study progressed (adjusted O.R = 74.1, 95% CI = 21.11–260.1, p<0.001). The changes in the "knowledge related to behaviour” (p = 0.01) and in the "behaviour related to reporting" (p<0.001) score was significantly higher in the intervention group. Specialist physicians and nurses (p<0.001), fulfilling additional positions (p<0.001) and those working in other places (p = 0.05) demonstrated a high rate of report. Lectures were preferable as a method to encourage ADRs reporting. The most convenient reporting tools were telephone and online reporting. Thus, implementation and maintenance of a continuous intervention program, by a pharmacovigilance specialist staff member, will improve ADRs reporting rates.

Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain

Objective

More than 100 million adults in the United States experience chronic pain, and prescription opioids are the third most widely prescribed class of medications. Current opioid overdose prevention efforts almost exclusively target illicit opioid users, and little is known about the experience of overdose among patients being treated for chronic pain (CP) with a prescription opioid.

Methods

Patients experiencing CP for three or more months and receiving a prescription opioid for pain management (N = 502) completed a self-report survey that asked questions about opioid overdose history, past 30-day risk factors, and knowledge of opioid overdose, overdose risk, and naloxone.

Results

Approximately one in five CP participants reported experiencing a lifetime overdose. CP participants reported engaging in several behaviors associated with overdose risk and were unlikely to have been trained to administer naloxone. Fewer than 50% of participants answered any knowledge item correctly. The likelihood of having experienced an overdose increased as the scores on the SOAPP-R and DSM-5 opioid use disorder checklist increased, and a SOAPP-R score of 7 or higher or meeting DSM-5 mild opioid use disorder criteria were significantly associated with reporting a lifetime overdose (85% and 84% of participants who experienced an overdose, respectively).

Conclusions

Opioid overdose occurs at a high rate among CP participants, and this group is relatively uninformed about risk factors for overdose. Established SOAPP-R and DSM thresholds provide an opportunity to identify participants at elevated risk for having experienced an opioid overdose. These data support development of additional concentrated efforts to prevent overdose among chronic pain patients.

Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting

BACKGROUND

Opioid use is highly prevalent in the United States and there has been an increased incidence in the rate of opioid-related overdose. While evidence suggests there are substantial differences in opioid use among rural versus urban settings, the rate of overdose and corresponding frequency of opioid overdose risk behaviors and overdose knowledge between rural and urban settings have not been examined.

METHODS

Individuals with opioid use disorder from rural (N=98) and urban (N=247) settings completed a self-report survey regarding their lifetime history of overdose and overdose risk behaviors. Participants also completed the Brief Opioid Overdose Knowledge (BOOK) questionnaire, a 12-item self-report measure of opioid overdose knowledge.

RESULTS

Overall, 35.6% of participants had experienced an overdose, and prevalence of overdose was significantly higher (p<.01) among rural (45.9%) vs. urban (31.6%) participants, though fewer rural participants reported past 30-day risk behaviors. There were few differences observed between the subset of rural and urban participants who had experienced an overdose, and fewer rural participants with a history of overdose reported past 30-day risk behaviors. Both rural and urban participants performed poorly on the BOOK, though the percent of correct responses was lowest among rural participants with a history of overdose.

CONCLUSION

Results demonstrate higher rates of overdose among rural opioid users, though rural participants were less likely to report recent risk behaviors. Results also suggest that knowledge regarding key factors related to opioid overdose is severely lacking, particularly among rural opioid users, which could be a potential target for future intervention efforts.

Brief Opioid Overdose Knowledge (BOOK): A Questionnaire to Assess Overdose Knowledge in Individuals Who Use Illicit or Prescribed Opioids

BACKGROUND

Opioid overdose is a public health crisis. This study describes efforts to develop and validate the Brief Opioid Overdose Knowledge (BOOK) questionnaire to assess patient knowledge gaps related to opioid overdose risks.

METHODS

Two samples of illicit opioid users and a third sample of patients receiving an opioid for the treatment of chronic pain (total N = 848) completed self-report items pertaining to opioid overdose risks.

RESULTS

A 3-factor scale was established, representing Opioid Knowledge (4 items), Opioid Overdose Knowledge (4 items), and Opioid Overdose Response Knowledge (4 items). The scale had strong internal and face validity. Patients with chronic pain performed worse than illicit drug users in almost all items assessed, highlighting the need to increase knowledge of opioid overdose risk to this population.

CONCLUSIONS

This study sought to develop a brief, internally valid method for quickly assessing deficits in opioid overdose risk areas within users of illicit and prescribed opioids, to provide an efficient metric for assessing and comparing educational interventions, facilitate conversations between physicians and patients about overdose risks, and help formally identify knowledge deficits in other patient populations.

Canadian poison control centres: preliminary assessment of their potential as a resource for public health surveillance

CONTEXT

In the United States (US) and Europe, surveillance based on calls to poison control centres has identified new hazards and evolving exposure trends. In Canada, the value of poison control centre calls as a tool for health hazard surveillance is largely unrecognized.

OBJECTIVES

This preliminary survey was undertaken to describe current operational characteristics and surveillance capacities at Canadian poison control centres and to determine potential for developing a Canadian poison control centre collaborative network.

METHODS

A structured quantitative-qualitative survey was administered to medical directors and clinical supervisors at the five Canadian poison control centres between March and May, 2012.

RESULTS

All five Canadian poison control centres operate 24/7 with each serving more than one province/territory. Annual call volumes range from 10,000 to 58,000. Data analysis is limited to detection of previously unrecognized hazards and short-term event-based adverse health monitoring. Currently no centre maintains systematic ongoing collection, integration and analysis of data. Constraints on personnel, resources and funding were identified as barriers to increasing capacity to provide and analyse call data.

CONCLUSIONS

The potential exists to use Canadian poison control data as a novel source of public health surveillance. That they serve as sentinels for new or unexpected exposure events, have real-time electronic call-record capacity and demonstrate an interest in developing and sharing their call-record information supports their integration into existing public health networks.

Adverse reactions to over-the-counter cough and cold products among children: the cases managed out of hospitals

BACKGROUND AND OBJECTIVE

Prompted by continuing concerns about the safety of over-the-counter (OTC) cough and cold medications, we examined the frequency and severity of pediatric adverse drug reactions (ADRs) to OTC cough and cold products reported to a major poison control center. The goal was to focus on cases that are usually managed out of hospitals and may not be recognized by the traditional adverse events surveillance and reporting programs.

METHODS

We conducted a retrospective review of electronic records on ADRs reported to the New Jersey Poison Information and Education System (NJPIES) through the National Poison Data System. Analyses included ADRs involving a single OTC cough and cold product. The number and proportion of reported ADRs to OTC cough and cold medicines were examined and compared by severity level between children <2 years of age, and children from 2 through 11 years of age.

RESULTS

A total of 91 pediatric ADRs to OTC cough and cold products were reported to the NJPIES from 2000 through 2007. Of these, 61 cases (67%) were of minor severity. A larger proportion of the children 2-11 years of age (21.2%), compared with children <2 years of age (8.0%), experienced a reaction of moderate to major severity.

CONCLUSIONS

While we found fewer ADR cases of moderate to major severity in younger children, our results call for a further review of the safety of OTC cough and cold medicines in children 2 years of age and older.

Assessing the need for communication training for specialists in poison information

INTRODUCTION

Effective communication has been shown to be essential to physician-patient communication and may be even more critical for poison control center (PCC) calls because of the absence of visual cues, the need for quick and accurate information exchange, and possible suboptimal conditions such as call surges. Professionals who answer poison control calls typically receive extensive training in toxicology but very little formal training in communication.

METHODS

An instrument was developed to assess the perceived need for communication training for specialists in poison information (SPIs) with input from focus groups and a panel of experts. Requests to respond to an online questionnaire were made to PCCs throughout the United States and Canada.

RESULTS

The 537 respondents were 70% SPIs or poison information providers (PIPs), primarily educated in nursing or pharmacy, working across the United States and Canada, and employed by their current centers an average of 10 years. SPIs rated communication skills as extremely important to securing positive outcomes for PCC calls even though they reported that their own training was not strongly focused on communication and existing training in communication was perceived as only moderately useful. Ratings of the usefulness of 21 specific training units were consistently high, especially for new SPIs but also for experienced SPIs. Directors rated the usefulness of training for experienced SPIs higher for 5 of the 21 challenges compared to the ratings of SPIs.

DISCUSSION

Findings support the need for communication training for SPIs and provide an empirical basis for setting priorities in developing training units.

Evaluation of adverse drug reactions reported to a poison control center between 2000 and 2007

PURPOSE

The likelihood of hospitalization caused by adverse drug reactions (ADRs) from commonly implicated therapeutic groups is discussed.

METHODS

A retrospective analysis of the computerized records of exposure cases involving pharmaceutical substances reported to the New Jersey Poison Information and Education System (NJPIES) was conducted from 2000 through 2007. The cases in the National Poisoning Data System that were categorized as an ADR were included in the study set. Only reports involving a single drug were selected for inclusion in the analyses. Characteristics of the ADRs, such as the sex and age of the patient, the therapeutic group involved, and the medical outcome of the exposure, were examined. Reports of ADRs with the most frequently implicated therapeutic groups were analyzed based on whether the patients were managed onsite, referred to a health care facility, or managed at a health care facility. The Adverse Drug Reaction Hospitalization (ADRH) index was calculated for all therapeutic groups, but the focus of the analyses was on the groups that were implicated in 5% or more of all ADRs.

RESULTS

A total of 454,520 cases of human poisoning exposure were reported to NJPIES from 2000 through 2007. Of these cases, 162,105 were exposures implicating a single drug, of which 5,461 (3.4%) were classified as an ADR. Of the 5,461 cases, 385 patients were admitted into a health care facility. Antidepressants had the highest ADRH index (20.4%) among the therapeutic groups implicated, and antimicrobials had the lowest (2.2%).

CONCLUSION

The analyses revealed a substantial variation in the likelihood of hospitalization associated with ADRs within different therapeutic groups. Among the groups that were most frequently implicated in ADRs, antidepressants showed the highest probability for an ADR-related hospitalization, followed by dietary supplements, herbals, and homeopathics and then by sedatives, hypnotics, and antipsychotics.

Suicidal antidepressant overdoses: a comparative analysis by antidepressant type

INTRODUCTION

The safety of antidepressants following overdose is critical because of the high risk of suicide attempts in depressed patients. This study was conducted to decrease the fatality rate of antidepressant overdoses by providing data to shift prescribing toward safer antidepressants.

METHODS

US poison control data for 2000-2004 were analyzed by 25 antidepressant types. Medical outcome differences were quantified using a hazard index (number of major or fatal outcomes per 1000 reported antidepressant ingestions).

RESULTS

Of 82,802 suicidal single-agent ingestions of identifiable antidepressants approved for use in the US, cases occurred predominantly in females and peaked in teens. Fatal cases peaked at 40 to 49 years of age. Suicidal ingestions of the SSRIs, SNRIs, and other antidepressants peaked in teens, lithium in the twenties, tricyclics and tetracyclics in the thirties, and MAO inhibitors in the forties. There were 40 major or fatal outcomes per 1000 cases. Weighted by antidepressant type, the mean hazard index for the 25 antidepressants was 79 (range: 0 to 292). Amoxapine (292), maprotiline (211), and desipramine (187) had the highest hazard indices. The tricyclic antidepressants, MAO inhibitors, maprotiline, and bupropion were in the more severe half of antidepressants, ranked by hazard index. All SSRIs had low hazard indices. Hazard index and exposure frequency were inversely correlated (R = -0.423, p = 0.035), while hazard index and use of critical care were positively correlated for the 25 antidepressant types (R = 0.797, p < 0.001). Clinical effect profiles for each antidepressant type are presented.

CONCLUSION

Suicidal overdose severity varied considerably by antidepressant type. Prescribing decisions should be informed by regularly updated comparative overdose severity data.

A Pilot Study Comparing Two Methods for Warfarin Management in Hospitalized Patients

Background:

The potential for medication errors in a hospital setting has led to a change from daily order writing to scheduled dosing. It has also been hypothesized that scheduled dosing may decrease the pharmacists' workload in a community teaching hospital.

Objective:

To evaluate the impact that scheduled warfarin dosing would have on patient safety for a pharmacist-run anticoagulation service.

Methods:

Two methods for managing warfarin in a pharmacist-run anticoagulation service were compared. A retrospective chart review was conducted on a random sample of 80 inpatients who received warfarin either from January 2006 through December 2006 (control/daily dosing group) or from January 2007 through March 2007 (scheduled dosing group). Patients not managed by pharmacists or with a target international normalized ratio (INR) range other than 2 to 3 were excluded.

Results:

A total of 35 patients met inclusion criteria; 20 patients were in the daily order (control) group and 15 were in the scheduled dosing group. A total of 7 doses were omitted in the daily dosing group, compared with none in the scheduled dosing group. Of the 7, 4 were omissions in administration and 3 were order omissions. In the control group, the dose was changed 47 times (36%) compared with 23 times (28%) in the scheduled dosing group. In the daily dosing group, 28 (22%) INRs were within the therapeutic range and 97 (78%) were in the nontherapeutic range. In the scheduled dosing group, 24 (25%) INRs were within the therapeutic range and 72 (75%) were in the nontherapeutic range.

Conclusions:

Scheduled dosing eliminated omission-type medication errors and was more efficient than daily dosing. The process change decreased pharmacist workload without having a negative impact on patient care.